Dos Rios Yacht Club
Member emergency Information – “Confidential”
(Each member & First Mate to complete a separate form and file in boat refrigerator)

Name: ____________________________________

Home Address: ____________________________________________________

Home Phone: _______________________

Cell Phone:__________________________

Spouse’s Name: ______________________ Spouse’s Cell_____________

Boat Name: __________________________ CF Number:______________

MEDICAL PROBLEMS- List major- Including pacemakers and metal joints

ALLERGIES: Medications and foods:

MEDICATIONS:

PHYSICIAN & CONTACT INFO:____________________________________

INSURANCE INFORMATION_________________________________________

EMERGENCY CONTACTS____________________________________________

Signature___________________________ Date______________