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Emergency Contact Form

March 11, 2015 by Homestay for Life

Emergency Contact Information

Name______________________________             Date_____________________________

 

In the unlikely event of an emergency, whom should we contact on your behalf ?

 

 

Primary Contact                                                   Secondary Contact

 

Name______________________________                 Name ________________________________

 

Address____________________________                 Address ______________________________

 

___________________________________                 _____________________________________

 

Telephone___________________________                Telephone          ___________________________

 

Cell Phone __________________________                 Cell Phone          ___________________________

 

E-Mail _____________________________                 E-Mail________________________________

 

In the unlikely event of a medical emergency in which you are unable to communicate, is there any information about you that the doctor needs to know ?

 

Medical Conditions_________________________________________________________________

 

_________________________________________________________________________________

 

Food Allergies_____________________________________________________________________

 

_________________________________________________________________________________

 

Allergies to Medicines_______________________________________________________________

 

_________________________________________________________________________________

 

List all medications that you are taking__________________________________________________

 

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