Emergency contact and medical information form
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Emergency contact and medical information

[ORGANIZATION NAME]

This form is voluntary except for at least one emergency contact. We will keep it private and secure, share it only with people who need it to help you in an emergency (such as first aiders, the person in charge of an activity or emergency responders), and use it for no other purpose. Please tell us if anything changes.

Name: [FULL NAME]

Role: [STAFF, VOLUNTEER, BOARD MEMBER OR PARTICIPANT]

Preferred phone: [PHONE]

Emergency contacts

First contact

- Name: [NAME]
- Relationship to you: [RELATIONSHIP]
- Phone: [PHONE]
- Other phone: [PHONE]

Second contact

- Name: [NAME]
- Relationship to you: [RELATIONSHIP]
- Phone: [PHONE]

Health information for emergencies (optional)

Leave any question blank if you prefer.

1. Do you have a serious allergy we should tell first aiders or emergency responders about? [ALLERGY AND USUAL RESPONSE, OR LEAVE BLANK]
2. Do you carry emergency medication, such as an epinephrine auto-injector or an inhaler? If so, where do you usually keep it? [DETAILS, OR LEAVE BLANK]
3. Would you need help to leave the building in an emergency? If so, what help? [DETAILS, OR LEAVE BLANK]
4. Is there anything else you want first aiders or emergency responders to know? [DETAILS, OR LEAVE BLANK]

For a child or young person (under 18)

Parent or guardian name: [NAME]

Phone: [PHONE]

In an emergency, if we can't reach you, we will call emergency services and follow their advice. [ADD ANY CONSENT FOR TREATMENT YOUR ACTIVITY REQUIRES, AFTER CHECKING YOUR STATE'S RULES AND YOUR INSURER'S ADVICE.]

Parent or guardian signature: [SIGNATURE] Date: [DATE]

Signature

I confirm this information is correct, and I understand how it will be used and stored.

Signature: [SIGNATURE] Date: [DATE]

For office use

Received by: [NAME] Date: [DATE]

Stored in: [LOCATION OR SECURE FOLDER]

Review due: [DATE]

Destroy by: [DATE OR EVENT, PER OUR DOCUMENT RETENTION POLICY]