Emergency Contact 2. Full Name: Relationship: Home Address: Email Address: Home/Cell Phone #: Work Phone #: Can the participant be released to this individual? Yes or No (circle one)
Emergency Contact 2. Name: Relationship to Minor: Phone Number: Participant Information Name: Date of Birth: Allergies (medical, food, environmental): Any Medical Condition: Medications you are taking: Name of Doctor: Phone Number: ( ) - INSURANCE INFORMATION Insurance Company: Name of Insured Member: Group # : Phone Number: Signed at , [city, state], this day of 20 . Print Name [or Parent or Guardian Name if under 18] Signature [or Parent or Guardian Name if under 18]
Emergency Contact 2. Name: Telephone: ( ): I, (“Registrant” or “I”), request that the U.S. Living Will Registry, with offices at 000 Xxxxxxxxx Xxx., XX Xxx 0000, Xxxxxxxxx, Xxx Xxxxxx 00000-2789 (“Registry”), electronically store a copy of my attached advance directive (living will and/or health care proxy), and provide a copy of the stored advance directive to any health care provider who requests it in conjunction with providing care to me. A “health care provider” is any hospital, doctor, skilled nursing facility, nursing facility, home health care agency/provider, ambulatory surgery facility, hospice, or any authorized employee of any of the foregoing. My registration is not effective until I receive written confirmation from the Registry, at the address I have provided above. I understand that I can only register through a Registry member Health Care Provider or a Registry Community Partner. The Registry’s member Health Care Providers and Community Partners are not owned or operated by the Registry, and they cannot change any terms of this Registration Agreement; any oral changes are not effective.
Examples of Emergency Contact 2 in a sentence
Name: Known As: Social Security #: DOB: Mailing Address: City: State: Zip: Physical Address: City: State: Zip: Phone Number: Email: Emergency Contact 1: Relationship: Phone: Emergency Contact 2: Relationship: Phone: Please read through the orientation packet you’ve been given, then initial the items below.
More Definitions of Emergency Contact 2
Emergency Contact 2. Name: Relationship to Child: Address: Phone: ( ) Child Full Name: Birthdate (d/m/y): Child's HEALTH CARD #
Emergency Contact 2. Phone: Alternate Phone: Email: In the event of an Emergency, does above named person have authority to authorize repairs? Yes No