Instructions: Copy and Paste to a word document of your choice.

Fill out and store in saddle bag, or with registration or insurance information.

EMERGENCY MEDICAL INFORMATION

In the event of an accident, DO NOT REMOVE HELMET until examined by a doctor - or patients airway is compromised.

If unobstructed breathing is present DO NOT REMOVE HELMET.

Name: _____________________________                                             Home Phone:_____________________

Address: ___________________________                                             Work Phone:______________________

City:_______________________________                                             Cell Phone: _______________________

                        State:_________  Zip:________

Date of Birth: _____________________           Sex: M / F              Social Security Number (optional):________________________

EMERGENCY CONTACT INFORMATION

Primary Contact: _______________________                                Secondary Contact:_____________________

Relationship: __________________________                                 Relationship:__________________________

Address: _____________________________                                Address:_____________________________

City, State, Zip: ________________________                                City, State, Zip:_________________________

Home Phone: _________________________                                 Home Phone:_________________________ 

      Cell Phone:___________________________                                 Cell Phone:___________________________       

    Work Phone:__________________________                                 Work Phone:_________________________

    Other:________________________________                                 Other:_______________________________ 

Medical & Insurance Information (Optional)

Blood Type: ______                                 Wear Contacts Y/N

Allergies to Medications / Other                                                        Medications now being used

1._______________________                                                      1.______________________________

2._______________________                                                      2.______________________________

3._______________________                                                      3.______________________________

Doctor:______________________________                                Special Needs and/or Health Problems

Address:_____________________________                             1.________________________________

City:________________________________                             2.________________________________

State:_________     Zip:_________________                             3.________________________________

Health Insurance & Related Info

Company:_____________________________

Policy/Group#:__________________________

Emergency Medical Treatment Authorization (Optional)

Signature authorizes emergency medical treatment by Doctor, Hospital or Emergency Medical Personnel when direct authorization cannot be obtained:

SIGNED:________________________________________________________    DATE:______________