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Emergency Contact Form

This form will be placed in your file and will also be kept in a backup location in the event of an emergency.

Personal Information

Medical Background - Disclosure is optional

Emergency Contacts

Contact #1

Contact #2

In an emergency we will contact the person(s) whose name(s) you provide in the Emergency Contact Section.  Please notify your emergency contact(s) about this designation.

In the event of an emergency, I authorize release of the above information:

Please enter your full name as it appears on your license or state-issued identification.