PAPER ARTS & MEMORIES

       EMERGENCY MEDICAL INFORMATION 

NAME:                                                                                                                                                                                               
                                             Last                                                                                                                First                                                                                      Middle 

ADDRESS:                                                                                                                                          

TELEPHONE:                                                                                                                                     

IN CASE OF EMERGENCY, PLEASE CONTACT: 

NAME:                                                                       TELEPHONE:                                                

NAME:                                                                       TELEPHONE:                                                

DOCTOR’S NAME:                                                  TELEPHONE:                                                 

The following information is strictly VOLUNTARY. 
This information will be given to medical personnel in case of an emergency. 
The information you provide could save your life! 

BLOOD TYPE (if known):                                                                                                                  

CURRENT MEDICATIONS:            
1.                                                                                 5.                                                                                                                                
2.                                                                                 6.                                                                      
3.                                                                                 7.                                                                      
4.                                                                                 8.                                                                       

ALLERGIES TO MEDICATIONS (list below): 
1.                                                                                 3.                                                                                                                                
2.                                                                                 4.                                                                       

List anything you would like medical personnel to know about you if you are unable to tell them. 
Use back of form if more space is needed. 

Signature____________________________________________________Date_______________