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Village of Michiana Police Department
Medical Information for Emergency
Chief Lynn Papke.
To assist our citizens, we have an emergency form that you may fill out. One copy should be put on your refrigerator. The other copy will be kept in the Police Office file in case of an emergency. You are under no obligation to fill this form out. It is just an attempt by your police to cover you in any emergency.
(Name)_____________________________________
(address) _______________________________________________________________
Local Telephone Number_________________________________________________________________
Doctors Name and Phone_________________________________________________________________
Person to Contact in Case of an Emergency:__________________________________________________
Please Mark (X) for any Special Conditions:
( ) Handicapped or bedridden
( ) Telecommunications Device for the Deaf
( ) Speech Impairment
( ) Blind
( ) Heart Problems
( ) Diabetes
( ) Seizure Disorder
( ) Oxygen
Please list any allergies to medication that you may have:
Please list medications you are currently taking:
Please write down any other information that you feel would be useful in an emergency.
Please sign and date document.
Signature: _________________________________________________ Date: ______________________
All information given to the Michiana Police Department is private and confidential, and will not be given to anyone except emergency personnel as needed.
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