Member Emergency Information Form

This information will be kept in a private file in the Minister’s office, accessible only by the Minister, to give aid to members in the case of an emergency.

Please complete this form as completely as possible; supporting information may be mailed to the office marked "CONFIDENTIAL."

Date

*

Member Contact Information

Member Name

*

Address

*

Phone

*

Best Email

*

This address will receive a confirmation email

Alternate address

BIrthdate

*

Three people who might be available to help in the case of an emergency

Emergency Contact 1

*

Phone

*

Email

*

Emergency Contact 2

Email

Phone

Emergency Contact 3

Email

Children (list addresses & phone numbers, if different from your own)

Child 1

Birthdate

Address

Phone

Child 2

BIrthdate

Address

Phone

Child 3

Birthdate

Address

Phone

Member Medical Information

Physician

Physician Phone

Do you have a Living Will?

*

Please select all that apply.

Yes No

Have you given anyone a Health Care Power of Attorney

*

Please select all that apply.

Yes No

Where are your Living Will and Health Care Power of Attorney document kept? (Provide a copy if possible.)

Medications

Medication 1 (Name, dose, purpose)

Medication 2 (Name, dose, purpose)

Medication 3 (Name, dose, purpose)

Medication 4 (Name, dose, purpose)

Medication 5 (Name, dose, purpose)

Other Medical Information

Medical Allergies, if any

Any other medical information we should be aware of?

Member Legal Information

Attorney

Phone

Do you have a legal will?

*

Please select all that apply.

Yes No

If yes, where is it located?

*

Do you have a Personal Representative/Executor

*

Please select all that apply.

Yes No

Name

Phone

Where do you keep your vital papers?

Member Animal Information

Do you have pets or other animals?

*

Please select all that apply.

Yes No

Describe type, how many

Veterinarian

Phone

Person who would care for your pets is your absence (name and phone)

Other information and wishes regarding animals

Description

This information will be kept in a private file in the Minister’s office, accessible only by the Minister, to give aid to members in the case of an emergency.

Please Fix the Following

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