PRINT, COMPLETE, SIGN AND MAIL TO:
Roane County HFH
PO Box 1124
Kingston, TN  37763
(865) 376-5770

Emergency Medical Information

Note:     All items require an entry. If you do not know or have no answer, then specify by entering “None”.

Name of Volunteer: _______________________________________________________

1)             In case of an emergency, please contact:   (“None” is not acceptable for this portion of form)

Name:                 _____________________________________________________________

Relation: __________________________________________________________________

Address: __________________________________________________________________

Phone:   (H) ________________________________________________________________

                 (W)________________________________________________________________

2)                    The following information may be needed by any hospital or medical practitioner not having
                access to the Volunteer’s medical history:

Allergies (medicine, food, insects, etc.): ___________________________________________

Medications being taken: _____________________________________________________________

Date of last tetanus shot: _____________________________________________________________

Physical impairments: _______________________________________________________________

Other: ____________________________________________________________________________

3)             Primary Care Physician:

                Name: ________________________________________________________________________

                Address: ______________________________________________________________________

                Phone: ________________________________________________________________________

4)             Health Insurance Coverage:

                Company Name: _____________________________________________________________

                Policy/ ID Number: ___________________________________________________________