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Emergency Contact Form
This information will only be used in case of medical emergency or arrest, and will be deleted immediately following the event. Please fill out as much or as little as you like, but do please include an emergency contact.
PLEASE WRITE THE NATIONAL LAWYERS' GUILD HOTLINE ON YOUR BODY (212)679-6018.
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* Indicates required question
Email
*
Your email
What is your name? (first and last)
*
Your answer
If your name appears differently on your ID, what name is used on your ID? (first and last)
This is in case you're arrested or hospitalized, and we need to locate you.
Your answer
What are your preferred gender pronouns?
Your answer
What is your address?
Your answer
What is your phone number?
Your answer
What is your date of birth?
Your answer
What is the name of your emergency contact? (The person we will call in case of arrest or medical emergency)
Your answer
What is your emergency contact's phone number?
Your answer
What is your emergency contact's relationship to you?
Your answer
Are you allergic to any medication?
yes
no
Clear selection
Any special instructions / conditions / info for EMS or paramedics?
Your answer
In case of arrest, what is your cell preference according to gender? (i.e. "women's," "men's," "single cell, etc.)
Your answer
Send me a copy of my responses.
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