Emergency Contact Date *Member name *Emergency contact name *Relationship *Phone (Mobile preferred) *Is there a Medical Practitioner that we should contact?Medical Practitioner PhoneMedical conditions and allergiesDo you have Diabetes? (Yes/No)Have you ever had any form of Epilsey? (Yes/No)Do you have any Medical, Physical or Mental disabilities that may adversely affect your ability to use power tools or machinery? (Yes/No)Do you have a Pacemaker or other condition that prohibits the use of a Defibrillator? (Yes/No)If you responded "Yes" to any of the above, please provide detailsDo you carry medication? (Yes/No)If "Yes" please provide detailsThe information that you have provided will remain confidential and only be used by HWMS to assist you in the case of a medical emergency.Submit Emergency Contact Form