Bozeman Community Teaching Center
Ascended Master Teachings for Spiritual Seekers
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In Case of Emergency - Contact Information Form for the KOFs of the BCTC
Please complete this
confidential
information sheet that will be used by the BCTC Board in case of accident or injury on teaching center property or for any other emergency.
Your Personal Information
Your Name
*
First
Last
Your Address
Type your information in the space
above
the words.
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombi
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepa
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Your Cell Phone
Your Home Phone
Your Work Phone
Email
*
Your Emergency Contact Person(s)
(1) Primary Contact Name
*
First
Last
Relationship To You
*
Phone Number
*
Email Address
(2) Secondary Contact Name
(Optional)
First
Last
Relationship To You
Phone Number
Email Address
Prayer Requests
In case of
serious
medical emergency,
check as many as apply.
Confidentially, I would like prayers given for me by the local BCTC prayer team.
Confidentially, I would like prayers given for me by the local BCTC and the TSL prayer teams.
I approve email notification to the BCTC general membership for serious situations.
Optional Information
Five Wishes
(Emergency Medical Treatment Information)
Do you have your Five Wishes completed?
Yes
No
No, I would like help with this.
*
Who has a copy of your Five Wishes?
First
Last
Will
Do you have a will?
Yes
No
No, I would like help with this.
*
Who has a copy of your Will?
First
Last
Power of Attorney
Do you have a P.O.A (Power of Attorney)?
Yes
No
I would like more information about this.
*
Who is your P.O.A.?
First
Last
Relationship To You
Phone
Email
Additional Information
Special Information
Is there any other special information you would like to share, such as allergies to certain medications, health issues, etc?
As the Boy Scouts motto says:
'Be Prepared.'
Thank you for your consideration.
Verification
For security purposes, please type any two digits.
*
Example: 12
This box is for spam protection -
please leave it blank
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