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Member Name

First Name

Last Name

Date of Birth

YYYY

Parent/Guardian One Name

First Name

Last Name

Cell Phone

(###)

###

####

Parent/Guardian Two Name

First Name

Last Name

Cell Phone

(###)

###

####

In Case of Emergency

All attempts will be made to notify parent/guardian first. In the event that neither parent/guardian can be reached, the Emergency Contact person will be notified.

Emergency Contact Name

First Name

Last Name

Relationship

Emergency Contact Phone Number

(###)

###

####

Alberta Health Care Number

Medical Information

Allergies

Please list all known allergies and the type of reaction. Indicate if you carry any form of treatment with you.

Health Conditions

Does the member have any health conditions, which would be important to communicate to health care providers in the case of an emergency?

Medication

Is the member taking medication? If yes, please specify, including dosage, time of day, and how often.

Optional Information

Update

It is very important that this form be kept current, please fill it out any time there is a change.

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