Emergency Contact Form Emergency Contact Form Name* First Middle Last Date of Birth* Month Day Year Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Primary Phone Number*Secondary Phone NumberEmergency Contact #1 (Name, Relationship, Phone Number)*Emergency Contact #2 (Name, Relationship, Phone Number)*For children & youth under 18, please provide the name, relationship, and phone number of an emergency contact person who is not a parent or guardianAllergies (optional) Medical Conditions (optional) Medications (optional) Primary Care Physician & Phone Number (optional) Preferred Hospital (optional) Additional Information Consent* I understand this information will be kept in the church office for access by administrative staff in the case of an emergency at the parish or in the event of contact tracing.Signature Δ