Legal Observer Volunteer Program Emergency Contact Form

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Thank you for your interest in volunteering with NLG-LA's Legal Observer Program covering Los Angeles County and Orange County. The safety of our legal observer volunteers is our top priority. We ask that you complete and submit this emergency contact form in order to volunteer with our program.

Email *

Full Name *

**As shown on your ID**

Birthdate *

YYYY

Your phone number *

Your email *

Primary Emergency Contact Name, Address, & Cell Phone Number *

Relationship to Primary Emergency Contact *

Secondary Emergency Contact Name, Address, and Cell Phone Number *

Relationship to Secondary Emergency Contact *

Primary Care Physician (Name & Contact Number if applicable)

Insurance Company & Policy # (if applicable)

Allergies to any medications *

A copy of your responses will be emailed to the address you provided.

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