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Emergency Information
The safety of each member is important to all of us at Assistance League of El Paso.
Everyone is encouraged to update your emergency information using our online form. It is important that the Chapter maintain the most current information in our database for each member.
Please update and re-submit online any time you have any changes in your medical history.
Press SUBMIT when finished.
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
Contact Person
*
Enter FIRST and LAST NAME of Contact Person
Your answer
Relationship
*
Relationship of Contact Person to you:
Your answer
Contact Person Phone Number
*
Enter CELL or HOME telephone for Contact Person. Use this format: 915-000-0000.
Your answer
Doctor
*
Enter name of family or primary doctor. This information will be provided to first responders.
Your answer
Doctor Phone Number
*
Enter telephone number for family or primary doctor. Use this format: 915-000-0000. This information will be provided to first responders.
Your answer
Hospital
*
Enter name of hospital you prefer. This information will be provided to first responders.
Your answer
Allergies / Medical conditions
This information is OPTIONAL, but may be helpful to first responders.
Your answer
Emergency Information completed
Thank you, please update as needed
Your answer
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