Star Rider Emergency Contact InfoThis information will be for the Star Rider Officers only! This form is voluntary and confidential and is intended for use only in case of an emergency on a group ride or event. |
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Member Name: _____________________________________________ |
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Home Address: _____________________________________________ |
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Home Phone: ________________________ |
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Emergency Contact #1 Name: ___________________________________ Phone:___________________________ |
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Emergency Contact #1 Name: ___________________________________ Phone:___________________________ |
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Allergic Reactions:___________________________________________________________________________ Special Medical Conditions:____________________________________________________________________ |
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Blood Type: ______________________ Hospital Preference:____________________________________________________________________________ |
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Medical Insurance: (Company) ________________________________________________ Policy Number: _____________________________________________________________ |
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