Emergency Info Form

Emergency Info Form

Church members are invited to submit emergency information to the church. This information will be stored in the church’s private database to have on hand for emergencies. You can include information about whom to contact in the case of an emergency, who can act as your general or medical power of attorney, where to locate your important documents, who your medical providers are, etc. If you have extensive notes, just copy and paste them into this form in the appropriate boxes–you are not limited to the box size .

Please do NOT submit financial details such as account or credit card numbers. Do not include you SSN or driver’s license number. Do not share private medical information. Although you are submitting this on a web site, the results will be emailed to the church, and email is not a safe way to share these details.

The church will do its best to keep your information private and secure, and to only share information when the request is deemed valid. By submitting information here, you release and hold harmless the church and its staff and volunteers from all liability related to your information.

    Emergency Contacts (list names, phone numbers, email addresses, relationship, whether any have power of attorney):

    Important Documents (document name, location):

    Medical Providers (e.g. primary doctor with phone, preferred hospital with address):

    Additional Emergency Info (no financial info or SSN!):

    Is this an update?
    This is the first time I've submitted information.This is an update to a previous submission.