MVB MEMBER EMERGENCY CONTACT MEDICAL INFORMATION

It is recommended that the information on the form below be copied to a Word document. The headings can be removed and information completed. After printing the document it may then be carried in a key tag attached to your boot at all times and is for emergency use only. It is responsibility of each member to update this information if there is a change in details. 

You can access a pdf version of this form here

 

Walker ID

 


 

Medical Information:

 

Name: ………........................................................................................................................

 

Address: …………………………………………………………………………………………............

 

State: …….......................

 

Post Code: ……………….

 

Emergency Contact Person:

 

Name: ……………………………………………………………………………………………….

 

Relationship: …………………………………………………………….

 

Phone Number…………………………………………………………...

 

Allergies: ……………………………………………………………………………………………

 

Medical Condition:………………………………………………………………………………….

 

Current Medications: ………………………………………………………………………………

 

.......................................................................................................................................

 

Do you have current immunization against Tetanus: YES / NO

 

Blood Type: ………………………………………………………………

 

Medicare Number: ……………………………………………………...

 

Private Health Insurance Fund: YES / NO

 

Fund Name: ……………………………………………………………...

 

Ambulance Subscriber: YES / NO

 

Healthcare Card Number: …………………………………………….

 

Any other relevant information: ............................................................................................

 

………………………………………………………………………………………………………..............

 

I give permission for Murray Valley Bushwalkers Inc to give first aid to me should the need arise: YES / NO

 

Signature: ……………………………………………………………….

 

 

Date: …………………………............

 

Privacy Statement:

The information contained in this form is for emergency use only and will be used if you are ill or injured whilst

participating in a Murray Valley Bushwalkers Inc activity. The information will only be accessed by the walk

leader or their delegate and given to the relevant medical and/or emergency services personnel.

PLEASE MAKE SURE YOU CARRY THIS FORM WITH YOU ON ALL MURRAY VALLEY BUSHWALKERS EVENTS. 

 


Ratified at MVB Inc Committee Meeting held on December 9 2011

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