Angler Emergnecy Contact Info Form

Anglers Name	Date of Birth
Address	City, State, Zip,
Home Phone	Cell Phone
Email Address
Medical Information or History	Check here if NO pertinent information
Medications currently taken	Check here if None Being Taken
Known or suspected allergies	Check here if none known
Emergency contact information
*Contact 1*	Name Relationship Address City, Home Phone Cell or Other Phone
Alternate Contact 2	Name Relationship Address City, Home Phone Cell or Other Phone
Alternate Contact 3	Name Relationship Address City, Home Phone Cell or Other Phone
Other Notes you feel may be important

____________________Parents or Guardians Signature
PRINT THIS FORM BEFORE YOU SUBMIT IT AND HAVE A PARENT OR GUARDIAN SIGN IT AS A PERMISSION FORM TO PARTICIPATE IN THE CLUB
You can either SUBMIT this form, or just fill it out (and print it with out submitting) and provide a hard copy to the club. If you choose to "Submit" the info will be emailed directly to the Club Youth Director, Greg Choiniere.