26^th North Carolina Troops

Emergency Information Sheet 

Name: _________________________________________ D.O.B. ________________

 Address:_______________________________________________________________

 Home Phone: (        )________________________ Cell: (        )__________________

 Emergency Contact: ____________________________________________________ 

Phone Numbers: (        )________________________  (        )___________________

 Blood Type: _________ Medical Problems:_________________________________

                                                                         __________________________________

 Medications: ____________________________________________________________ 

 Allergies: _______________________________________________________________

 Medical Insurance: ______________________________________________________

 Medical Group #: __________________________  Member ID #: ________________

 We will be using this information to make medical cards for all members to carry on their persons when at an event.  This information will be used if you might become unconscious and the medical teams and hospitals would have this information there to be able to treat you quickly and safely. 

Please fill out and mail to: Lt. Ronnie Overby

                                              1225 Front Street

                                              Eden, NC 27288 

                                                            Or 

Email: thefireman@triad.rr.com or proverby@yahoo.com

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