Adult emergency form 2026

1. Click ‘Get Form’ to open the adult emergency form in the editor.
2. Begin by filling out Section 1, which includes basic contact information. Enter the adult’s last name, first name, middle name, home address, city, state, zip code, and date of birth. Provide up to three telephone numbers for easy contact.
3. In case of an emergency, list two emergency contacts in the designated fields. Include their names, relationships to the adult, street addresses, cities, states, zip codes, and multiple telephone numbers.
4. Proceed to Section 2 for insurance information. Fill in details such as the insurance carrier's name and policy number. Attach a photocopy of the policy holder’s insurance card as proof.
5. In Section 3, provide health information. Indicate any allergies or medications being taken. Note any medical or mental health concerns that should be communicated to program staff.
6. Finally, review your entries for accuracy and sign at the bottom of the form to give consent for medical treatment if necessary.

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