Emergency Contact Information

EMERGENCY CONTACT FORM

Please create a separate submission for each individual resident.
Resident’s Name*
Enter First & Last Name for ONLY one person
Address*
Gallery Street Address
Email Address*
example@example.com
Mobile Phone Number for Emergency Alerts
Data rates may apply. Enter ONLY a mobile phone number, else leave blank.
Alternate Phone Number, if any
Enter either land line or mobile number.
1st Emergency Contact*
First & Last Name
Relationship to Resident*
Address
Phone Number*
Alternate Phone Number
2nd Emergency Contact
First & Last Name
Relationship to Resident
Address
Phone Number
Does anyone in the community have a key or key code to your house?*

YesNo
If yes, who?
First & Last Name
Safety Tip: If you may need assistance to evacuate in the event of an emergency, make sure at least 2 neighbors are aware of your situation.
I alone shall be responsible for keeping the information contained on this emergency contact form current. I will notify Talega Gallery Community Association when I believe the information on this form should be changed by providing a new and updated form. I release management and the Talega Gallery Community Association from any liability or responsibility with the dissemination of same information.
Signature (Use your mouse or finger)*

Clear
Today's Date*

MonthDayYear
Date
Update Date

MonthDayYear
Date
Medical Information
Date of Birth

MonthDayYear
Date
Blood Type

A-A+O-O+B-B+AB-AB+
Allergies
Primary Care Physician
Phone Number
Address
Medical Conditions: Please list in case an emergency occurs
Separate by commas
Medications: Please list in case an emergency occurs
Separate by commas
Medical Equipment: Please list any equipment you currently use
Confidentiality:
Please tell us who, if anyone, is entitled to access the information contained in this emergency medical information sheet. The management of the association will not give this information to anyone other than your community manager, support staff, and emergency medical personnel, unless otherwise authorized by you.
I hereby authorize and approve management to release the above medical emergency information to those people indicated above. I also authorize and approve management to contact those individuals listed as “emergency contact(s)” above should the need arise during my occupancy at this association.
Date

MonthDayYear
Date
Signature
Date

MonthDayYear
Date
22 Calle Galeria San Clemente, CA 92673 (949) 361-4685

Talega.gallery@seabreezemgmt.com
Should be Empty:

EMERGENCY CONTACT FORM

Medical Information