Emergency Contact & Medical Info Sheet

Confidential — For Internal Use Only

Client Information

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Emergency Contact Name

First Name

Last Name

Relationship to client

Phone Number

(###)

###

####

Alternate Phone (if available)

(###)

###

####

Secondary Emergency Contact (optional)

First Name

Last Name

Relationship

Medical & Emergency Infor (Basic)

Preferred Hospital

Know Conditions (e.g., diabetes, seizures, falls risk)

Please list only information relevant in an emergency situation

Medications (Optional - only if relevant to safety)

Do Not Resuscitate (DNR) Order on File?

(Note: MWAF volunteers are note medical professionals and cannot make medical decisions)

Yes

Unknown

Any Additional Notes (e.g., oxygen use, mobility needs):

Confidentiality Notice

This form is only accessible to MWAF volunteers and staff who are assigned to the client and need this information in case of emergency. It will be stored securely and treated with respect and discretion.