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Emergency Contact Form
All information provided will be kept confidential, and destroyed after the action. This information will only be used in case of medical emergency or arrest.
* Indicates required question
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)
*
Your answer
What pronouns do you use? (He/him, She/her, They/them)
Your answer
What is your address?
Your answer
What is your phone number?
Your answer
What is your date of birth?
*
MM
/
DD
/
YYYY
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?
Your answer
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
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