Over the Hill Hikers Emergency Contact Sheet

  

Your Name:  ___________________________________________________

Date of Birth: ___________________________________________________

Cell Phone #: _____________________________  password to unlock cellphone: _______________

Street Address: ___________________________________________________

Town / State / Zip ___________________________________________________

Emergency Contact Name: ___________________________________________________

Relationship to you: ___________________________________________________

Their address: ___________________________________________________

Do you have any health concerns that rescuers should be aware of?

___________________________________________________

Are you taking any medications? ___________________________________________________

Your primary physician? ___________________________________________________

Their phone #: ___________________________________________________

Do you have any life threatening allergies? _______________________________________________

Are you an organ donor?

Do you have any medications in your pack, such as Epi-pen, or heart condition medications?  If so, where are they? ___________________________________________________

Who is your insurance provider? ___________________________________________________

Policy #: ___________________________________________________