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."

 
Member Contact Information

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

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Member Medical Information

 
 
Please select all that apply.
Please select all that apply.
 
 
 
 
Medications

 
 
 
 
 
Other Medical Information

 
 
 
 
 
 
 
 
Member Legal Information

 
 
Please select all that apply.
 
Please select all that apply.
 
 
 
 
 
 
Member Animal Information

Please select all that apply.
 
 
 
 
 
 
 
 
 
 
 

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.