Part 1 (front)
Mutual Aid Disaster Relief in Haiti — Emergency Contact and Medical Form
E-mail one copy to Kyla [name redacted] at [email redacted]
Print out and keep one copy with your group
In an Emergency Contact:
Appellex En Cas D'Urgence:
Kyla [name redacted]
001-[number redacted]
[email redacted]
NAME:
TRAVEL DATES:
TEAM:
In this document:
1. Your ID information
2. Your Medical History
3. Emergency contacts
US Embassy Consular Task Force in Port au Prince: 509-2229-8942
Part 1 (back)
Your ID Information
Name I go by:
Full legal name (what's on your ID):
Contact Info
Email:
Phone:
Permanent address:
Current address (if different):
Identification Info
Date of birth: month: day: year:
Gender on ID:
Passport #:
Specify State ID or other type of ID:
ID #:
Social Security #:
"The Department of State strongly advises U.S. citizens traveling to or residing in Haiti to register either online at https://travelregistration.state.gov or with the Consular Section of the U.S. Embassy in Port-au-Prince." Did you register with the Embassy? YES / NO
Physical Description
Height:
Weight:
Hair:
Eyes:
Age:
Other Physical Description (hair length, skin color, tattoos, eyeglasses, etc.):
Special concerns: I might be targeted, separated, or treated differently because I'm (trans, gender variant, not born in the U.S., on probation, of color, a subculture kid, something else, some combination of the above), etc.:
Part 2 (front)
Mutual Aid Disaster Relief in Haiti — Emergency Contact and Medical Form
E-mail one copy to Kyla [name redacted] at [email redacted]
Print out and keep one copy with your group
In an Emergency Contact:
Appellex En Cas D'Urgence:
Kyla [name redacted]
001-[number redacted]
[email redacted]
NAME:
Medical History
Use an additional page if needed.
Blood type:
Allergies [Include medicines, foods, animals, insect bites and stings, and environment (dust,
pollen, etc. State ALLERGEN – REACTION – MEDICATION REQUESTED as applicable]:
Medications [list all prescription, over-the-counter, anti-malaria, and natural medications you
are taking. State NAME – DOSAGE – FREQUENCY – SIDE EFFECTS – REASON FOR
TAKING as applicable]:
Yellow card vaccinations [Tetanus? Hep A/B? Typhoid? MMR? Rabies?]:
Part 2 (back)
Pertinent history [include recent illnesses, accidents, operations, & hospitalizations; ongoing or
known diseases/issues like asthma, diabetes, seizures, high blood pressure, heart disease, mental
illness, etc., etc., etc.]:
Part 3 (front)
Mutual Aid Disaster Relief in Haiti — Emergency Contact and Medical Form
E-mail one copy to Kyla [name redacted] at [email redacted]
Print out and keep one copy with your group
In an Emergency Contact:
Appellex En Cas D'Urgence:
Kyla [name redacted]
001-[number redacted]
[email redacted]
NAME:
Emergency Contact Info
NOTE: #1 Contact Person is for any and all emergencies—a parent, partner, etc. Add more if needed, and feel free to specify when (not) to call. (example: "call only if delayed by [some date]"). Setting up YOUR emergency contacts with instructions for further actions on your behalf — emergency decision-making, fundraising, contacting a boss/professor, etc. — makes my job a lot easier and faster. Feel free to pass my contact info on to your contacts, within reason: Kyla [redacted] – [redacted] – [redacted]
#1) In case of emergency, please call
NAME: RELATION:
PHONE: E-MAIL:
And tell them:
Part 3 (back)
#2) In case of emergency, please call
NAME: RELATION:
PHONE: E-MAIL:
And tell them:
#3) In case of emergency, please call
NAME: RELATION:
PHONE: E-MAIL:
And tell them: