EATON COUNTY 9-1-1 EMERGENCY MEDICAL INFORMATION
NAME: ____________________________________________________ DATE: _________________________
ADDRESS: __________________________________________________________________________________
CITY: ________________________ STATE: _________ ZIP: _______________ PHONE: _______________
RACE: _____ SEX: _____ DATE OF BIRTH: ____________ HEIGHT: _______ WEIGHT: _____________
HAIR COLOR: _________ EYE COLOR: _________ SOCIAL SECURITY: ___________________________
DRIVER’S LICENSE: __________________________________________________ STATE: _______________
VEHICLES: __________________________________________________________________________________
_____________________________________________________________________________________________
IMPORTANT MEDICAL INFORMATION/NEEDS: _________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
EMERGENCY CONTACT:
NAME: ____________________________________________________ HOME PHONE:____________
ADDRESS: _______________________________________ WORK PHONE: ______________
CELL PHONE OR PAGER: (specify)_______________________________________________________
NAME: ___________________________________________ HOME PHONE:_______________
ADDRESS: ________________________________________ WORK PHONE: ______________
CELL PHONE OR PAGER: (specify)_______________________________________________________
Requested by: ______________________________ Agency: __________________________________
Return to:
Bob Robison, Supervisor
Eaton County Central Dispatch
911 Courthouse Dr.
Charlotte, MI 48813
517-543-4948