Information for Emergency Medical Card

**Personal information**
Name
Home Phone
Address
City/State/Zip
Birth date
Insurance Co (opt)
Policy Number (opt)

**Medical information**
Primary Physician
Phone
Blood Type
Medical Conditions and/or History
Medications
Allergies

**Contact Information**
Emergency contact
Phone
Alternate phone
Emergency contact
Phone
Alternate phone

The purpose of this form is to collect pertinent medical information about the club member in case of an emergency. This is strictly a voluntary opportunity. This information will be kept confidential and will only be used to produce emergency medical information cards. Each card will be redistributed back to the club member upon completion. Please return your completed form to me at the next meeting, or mail it to me at the address on the front page. One form should be completed for each adult club member.

Thanks!!

Melissa Reisz