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					                                        HEALTH EMERGENCY LIFESAVING PARAMEDICS FOUNDATION INC.
                                              VICTORIA SUITES BLDG., TIRSO NERI STREET, DIVISORIA, CAGAYAN DE ORO CITY.
                                                                     HOTLINE # 4-1-1 or 74-11-11
                                                             Globe: 0917-7040-411 / Smart: 0999-9990-411


                                                      MEMBERSHIP ENROLLMENT FORM
IMPORTANT: Kindly fill-up all the necessary space below legibly and clearly. One (1) form for each person must be used to enroll. You may scan and email to:
helprescue411@yahoo.com.ph or have it sent to HELP Rescue 411 Office at the address indicated above or submit the form with the payment to Bodytouch
Massage and Health Spa at level 1, Robinson Mall or Bodytouch Rosario Arcade branch, Limketkai Center. Membership will be activated once the form has been
received together with the payment. If payment has been deposited to our account (BPI bank, Account name: FM health Emergency, Current account no. 9333-
0539-15) attach the proof of payment (deposit slip). Membership ID card will be issued thereafter. ALL INFORMATION CONTAINED HEREIN WILL BE CONFIDENTIAL.

               LAST NAME                                         FIRST NAME                                            MIDDLE NAME
NAME
DATE OF BIRTH                           AGE                    GENDER                           RELIGION                             BLOOD TYPE
 MM          DD           YYYY
                                                              MALE         FEMALE
CIVIL STATUS                                                                                    NATIONALITY

    SINGLE           MARRIED     SEPARATED          WIDOWED                                          FILIPINO          OTHERS
                                                           PERMANENT HOME ADDRESS
HOUSE NUMBER          BUILDING NAME                                        STREET NO.           STREET NAME                          SUBDIVISION / VILLAGE

BARANGAY / TOWN                                     CITY / MUNICIPALITY                         PROVINCE                                          ZIP CODE

TELEPHONE NUMBER                  FAX NUMBER                               MOBILE NUMBER                             EMAIL ADDRESS


                                                                EMPLOYMENT / SCHOOL
COMPANY / SCHOOL NAME                                                                                DESIGNATION


HOUSE#/BUILDING NAME/STREET NAME                     SUBDIVISION/ BARANGAY                           CITY/PROVINCE                            ZIP CODE


TELEPHONE NUMBER                  FAX NUMBER                               MOBILE NUMBER                                EMAIL ADDRESS


                               HOSPITAL AND ATTENDING PHYSICIAN OF CHOICE IN CASE OF EMERGENCY
HOSPITAL / CLINIC NAME                                                                           ATTENDING PHYSICIAN
1                                                                                                1
2                                                                                                2
3                                                                                                3
                                              CONTACT PERSONS TO CALL IN CASE OF EMERGENCY
CONTACT PERSON                                CONTACT NUMBER               CONTACT PERSON                                                 CONTACT NUMBER
1                                                                          4
2                                                                          5
3                                                                          6

                                      HISTORY OF PAST / PREVIOUS DISEASES/PREVIOUS OPERATIONS
PARTICULARS                                            DATE                        HOSPITAL / CLINIC                            DOCTOR’S NAME
1
2
3
                                 IF YOU SUFFER FROM ALLERGIES, PLEASE STATE KNOWN ALLERGENS
1                                 2                                                3                                            4

5                                 6                                                7                                            8


DISEASES PREVALENT IN THE FAMILY:        HPN        DIABETIC MELLITUS           ALLERGY      ASTHMA             TB      HEART DISEASE        CANCER


IMMUNIZATIONS:           BCG      DPT         OPV     HB        HA        MMR          OTHERS
                                              PRESENT ILLNESS AND MEDICATIONS TAKEN (if any)
ILLNESS                           MEDICATION                                       ILLNESS                                      MEDICATION
1                                                                                  4
2                                                                                  5
3                                                                                  6
                                                                           HABITS
SMOKER:        YES      NO                    ALCOHOLIC DRINKER:          YES          NO              DRUG DEPENDENT:              YES     NO

IF YES, HOW FREQUENT?                         IF YES, HOW FREQUENT?                                    IF YES, HOW FREQUENT?
                                         TERMS AND CONDITIONS
    1.   HELP Rescue 411 offers HELP Card membership program to all Kagay-anons, within Cagayan De Oro City limits (Iponan to
         Puerto, Lumbia to Macabalan). It aims to focus in giving benefits to people who need fast response in ambulance service
         and protection in emergency medical situations.

    2.   A membership enrollment form/clinical data sheet must be filled up and submitted to any of the following :

         a.   Thru email: helprescue411@yahoo.com or ems@helprescue411.com
         b.   Victoria Suites or HELP Rescue 411 Offices besides PAL office along Tirso Neri Street, Cagayan De Oro City.
         c.   Bodytouch Massage and Health SPA at level 1 Robinsons Mall and Bodytouch Rosario Arcade branch, Limketkai Center

    3.   Activation of HELP CARD membership starts upon the issuance of receipt of enrollment form, together with the payment of
         membership fee. It is effective for one (1) year only.

    4.   HELP Card membership entitles the member to avail FREE and unlimited use of the ambulance during emergency calls to
         HELP Rescue 411’s 24/7 emergency medical assistance. It covers only the period during which the member is attended to by
         the HELP Rescue 411 medical and nursing staff and ends upon proper endorsement to the emergency room of the receiving
         hospital.

    5.   24/7 Emergency medical assistance of HELP Rescue 411 can be put into action by calling landline hotline numbers 4-1-1 or
         74-11-11 or Globe: 0917-7040-411 or Smart: 0999-9990-411

    6.   HELP Rescue 411 will not be held responsible for failure to provide services or for delays caused by force majeure such as,
         but not limited to, natural disasters, strikes or other conditions beyond its control. All claims arising under the agreement
         shall be vested exclusively in the courts of Cagayan De Oro City.

    7.   HELP Rescue 411 has the right to be subrogated on the amount of the service it has provided to the member(s) or to any
         party responsible for acts which gave rise to injury or illness to its Paramedics.

    8. The member hereby grants full authority to the HELP Rescue 411 staff to do and execute any and all acts deemed proper for
         his/her best interests.




                                            TRUTH CERTIFICATION
         I hereby certify the truth of all representation made in this application, and acknowledge that the HELP Rescue 411 service
agreement may otherwise be invalidated with costs chargeable to me. I further authorize any physician, paramedic, clinic or hospital
where I have been treated to disclose and provide the company with the medical, dental or clinic findings relative to the medical
representative above.

I hereby authorize HELP Rescue 411 to input the foregoing personal data into their computer system.

Signed this _____ day of ____________________, 20 _____ at ___________________________________, Philippines.




                                     _________________________________________________
                                                 Signature of Applicant Member



Important:
        HELP Card new member shall receive a confirmation text and a membership ID card within 7 working days from approval of
membership enrollment. If you have not received a text confirmation after 7 working days please contact or visit HELP Rescue 411
office.
                       Health Emergency Lifesaving Paramedics Foundation Inc.
                       Victoria Suites Building, Tirso Neri street, Divisoria, Cagayan De Oro City
                       Landline Hotline Numbers: 4-1-1 or 74-11-11
                       Smart: 0999-9990-411
                       Globe: 0917-7040-411
                       Email: helprescue411@yahoo.com / ems@helprescue411.com
                       Website: www.helprescue411.com

				
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