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.)
