Mecklenburg County AmeriCorps Project by 05GoB17T

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									NC LiteracyCorps ENGAGE AmeriCorps Project
Member Emergency Contact


Member Information:

Name:         _______________________________________________________________________

Address:      _______________________________________________________________________
              _______________________________________________________________________

Phone(s):     _______________________________________________________________________

Emergency Contact Name (Family or friend to contact in the case of an emergency)

Name:         _______________________________________________________________________

Relation to Member:   _________________________________________________________________

Address:      _______________________________________________________________________

              _______________________________________________________________________

Phone(s):     ________________________________________________________________________


Name:         _______________________________________________________________________

Relation to Member:   _________________________________________________________________

Address:      _______________________________________________________________________

              _______________________________________________________________________

Phone(s):     ________________________________________________________________________

Any allergies?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Any medical information it would be important to know in the case of an emergency?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

								
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