Emergency Contact Form
(Must be Someone Not On The Ride)

Emergency Contact Name___________________________________________________ 

Emergency Contact Home Phone Number______________________________________

Emergency Contact Cell Phone Number________________________________________

Emergency Contact Street Address____________________________________________

Emergency Contact City / State_______________________________________________

My Name is____________________________________________________

My Medical Plan is _____________________________________________

My Group Number is ___________________________________________

My ID Number is ______________________________________________

My Blood Type is______________________

I'm Allergic to___________________________________________________________

                        ___________________________________________________________

                        ___________________________________________________________

                        ___________________________________________________________

According to the guidelines of the Uniform Anatomical Gift Act, I choose, upon my death to:
                                               [place an X on the appropriate line(s)]

1.______Donate any of my organs, tissues or parts
2.______Donate a PACEMAKER (date implanted_________________)
3.______Donate parts, tissues or organs listed___________________________________________
                    ________________________________________________________________________
4.______Not Donate any organs, parts, tissues or PACEMAKER

________________________________________________________________________
                                   Signature                   (Keep in your Left Front Pants Pocket)                   Date