Emergency Contact Information – Bozeman Community Teaching Center

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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 AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
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?YesNoNo, I would like help with this.
* Who has a copy of your Five Wishes? First Last
Will
Do you have a will?YesNoNo, 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)?YesNoI 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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