Emergency Medical Information Form

All members and Guests need to have an Emergency Medical form on file with us. In the event you are incapacitated we need to provide this information to Medical authorities for you. Please print out form, and bring to the event you will be attending. It is MUCH easier to fill this out at home where you have easy access to needed information! We will keep all information confidential. The form will be returned to you at the end of your stay.

Raven-Wolf Nature Sanctuary

Emergency Medical Information Form

Legal Name:  ___________________________________________

Birthdate (mm/dd/yyyy) __________________

Common/Craft Name: _____________________________________

Mailing Address:          City___________________________________________________

State_______________________________Zip_________________

Phone: (Home)___________________ (Cell)___________________

E-Mail: ______________________________________

Legal Guardian (If Minor): _______________________

Membership # ___________

Sponsor (If Guest): _____________________________

Medical Conditions (Allergies, Injuries, Physical Restrictions, Health Issues, Etc.):

_________________________________________________________

_________________________________________________________

Medications: __________________________________________________________

__________________________________________________________

Blood Type: ____________________

Organ Donor:        Yes_____       No_____

Emergency Contacts (For serious medical conditions, Please include your Doctor as one of these):

Name/Relationship: _________________________________

Phone: _________________

Name/Relationship: __________________________________

Phone: _________________

Name/Relationship: __________________________________

Phone: _________________

Medical Insurance Information: ____________________________________________________

I give my permission for medical, dental, or any other treatment deemed appropriate to be performed on the individual identified by the information on this page.

I also fully understand and accept that Raven-Wolf Nature Sanctuary and all Staff, Representatives, and Associates thereof are not held liable in any way for any illness or injury incurred thereby.

Signature: ________________________________________ 

Date: __________________

(For Minor, must be that of Legal Guardian)

*NOTE: If the individual identified on this page is a minor, a notarized form MUST be completed allowing permission of legal guardian for any emergency treatment to be performed.

(See “Minor Child Guest Registration” on left side of page.)

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