info for person wearing the medical id dog …...2015/02/27  · select bracelet size q s...

Mail completed application to: MedicAlert Foundation, PO Box 21009, Lansing, MI 48909-1009 or Fax to: 209.669.2495

SPONSORED MEMBERSHIP FORM

MEDICAL CONDITIONS / ALLERGIES / MEDICATIONS / DEVICES

PROOF OF HARDSHIP

INFO FOR PERSON WEARING THE MEDICAL ID

FIRST NAME MIDDLE NAME LAST NAME

MAILING ADDRESS CITY STATE ZIP

PHONE EMAIL ADDRESS

DATE OF BIRTH GENDER

EMERGENCY CONTACT NAME EMERGENCY CONTACT EMAIL

EMERGENCY CONTACT PHONE #1 PHONE #2

PRIMARY PHYSICIAN PHYSICIAN PHONE

MEDICAL CONDITIONS & DEVICES:

ALLERGIES: List all known food, drug or other allergies

MEDICATIONS: List all medications and dosages, including inhalers

Engraving: The MedicAlert® ID will be engraved with your MedicAlert ID number and our 24-hour emergency response number, enabling responders to assist you immediately. To provide the best service possible, our trained staff will determine what additional critical information (e.g., a medical condition) should be engraved on the ID.

Important: By accepting service with MedicAlert Foundation, you authorize MedicAlert to release all information about you in emergencies. MedicAlert relies upon the accuracy of the information you supply. You, therefore, agree to defend, indemnify, and hold MedicAlert (including its employees, officers, directors, and agents) harmless from any claim or lawsuit brought by you or others for injury, death, loss or damages arising in whole or in part out of your provision of incomplete or inaccurate information to MedicAlert. Furthermore, as aregiver for the member named above, you hereby represent and warrant to MedicAlert that you have full power and authority, as the duly authorized representative of the child(ren), to enroll and act on their behalf.

SIGNATURE OF MEMBER DATE(A parent or guardian signature is required for members under the age of 18.)

MedicAlert Foundation is a 501(c)(3) nonprofit organization. ©2015 All rights reserved. MedicAlert® is a U.S. registered trademark and service mark of MedicAlert Foundation International.

MEDICALERT MEDICAL IDS Please choose one ID.

CLASSIC STRETCH BAND

SHOE TAGS

q A664(limited engraving space)

q A661

STAINLESS STEEL BRACELETS

PENDANTS

Select Bracelet Sizeq 5” q 5½” q 6” q 6½” q 7” q 7½” q 8” q 8½” q 9”When selecting size, please measure your wrist snugly and add ½”.

Select Bracelet Sizeq S (6”) q M (6.75”) q L (7.5”)

q S (5”-6”) q M (6.5”-7.5”) q L (8”-9”)

Select Bracelet Sizeq S (5”-6”) q M (6.5”-8”)

q A751q A156 (petite)q A491 (lg)

q A657 q A658

q A739q A740 (lg)

q A659q A729 (lg)

q A655

q A656

q A601 q A600

DOG TAGS (30” beaded chain necklace)Not recommended for children under 12.

SILICONE COMPETE BRACELETS

REFLECTIVE SPORTS BANDS

SILICONE PLAY BRACELETS

q A832 q A837 q A831

q A833 q A834 q A830

q A843 q A840 q A841

q A823 q A824 q A826

q A827 q A828

q A829

q A842

q A825

q A602 q A604 q A603

q A605

q A734

q A738 (BLACK)q A721 (RED)q A722 (STEEL)q A730 (PURPLE)

q A507 (RED)q A737 (BLACK)q A509 (STEEL)

Chain Size q 26” q 30”

q A126q A091 (lg)

SWEETHEART CHARM BRACELET

q A794(limited engraving space)

q A795(HEART)

q A096

q Male q Female

Proof of hardship is required for approval of MedicAlert sponsored membership. This proof can be supplied in the form of a letter or statement from the individual requesting the sponsorship or a copy of a state or federal government public assistance program card. For more information please visit our website at www.medicalert.org/donate/sponsored-membership