Staff Emergency Information2025-2026 Name * Date of Birth * Email * Phone * (###) ### #### Car Make, Model, Color Emergency Contact Name * Emergency Contact Phone * (###) ### #### Preferred Hospital Primary Care Provider Name Primary Care Provider Phone (###) ### #### Primary Care Provider Address Health Insurance Provider Insurance Member ID Secondary Health Insurance Insurance Member ID List any emergency medical concerns/allergies Today's Date * MM DD YYYY By typing your name below as a digital signature, you give permission to The Discovery Center, licensed by the Department of Consumer and Industry Services, to secure emergency medical and/or emergency surgical treatment in the event you are unable to make such decision. * Thank you!
