Emergency Information Form

Please include as much information as you have available. The more details provided to emergency personnel the better they can help you. All information will be stored in a confidential location and only used in case of an emergency. This information may save your life!

To the form

The Basics

Today's Date:
Your Name:
Your Boat Name or Street Address:
Phone (Include International Dialing Prefix): Email:

Emergency Contact

Emergency Contact Name:
Relationship To You:
Phone (Include International Dialing Prefix): Email:

Your Personal Information

Where do you store documents such as passport on your boat or in your home:
Date of Birth: Blood Type:
Allergies:   
Existing Medical Conditions:    
Current Medications:     
Do you have a living will or a do not resuscitate order? Yes No
Where is this located?

Your Doctor & Insurance

Name of Primary Doctor:
Phone (Include International Dialing Prefix): Email:
Do You Have Medical Insurance (VA, Seguro Popular, Medicare, etc)?   Yes No
Name of Insurance Provider: Policy Number:
Phone (Include International Dialing Prefix): Email:
Evacuation Insurance Provider: Policy Number:
Phone (Include International Dialing Prefix): Email:

Click here to confidentially send your information to Club Cruceros:

Click to print the form:  
We recommend you laminate this printed form and keep it in plain view near the entrance to your boat or home.

Please be assured, your information will be held in a secure location and only used in case of an emergency.