River Road Unitarian Universalist Congregation

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River Road Unitarian Church

Emergency Contact Form

The ordained Ministers and the Pastoral Care Team are dedicated to and pledge confidentiality for the storage and use of the information you provide on this form. The sole purpose of this form is to help the Ministers or Pastoral Care Team reach your emergency contact(s) in the case of an emergency.

Your Name:      Date of Birth:

Address:

Phone Number:      Cell:

Email address:

 

EMERGENCY CONTACT(S)

Name:      Relationship to You: (e.g., son, friend, etc.)

Home phone:      Work phone:      Cell phone:

 

Name:      Relationship to You: (e.g., son, friend, etc.)

Home phone:      Work phone:      Cell phone:

 

If applicable, name of person who has your medical power of attorney:

Name:      Phone number(s):

 

PHYSICIAN(S)

Name:      Phone number:

Name:      Phone number:

Allergies to foods or medications:

Where do you keep a list of your current medications and dosages?

Location to the keys of your house: