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 medicaons 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 addional crical informaon (e.g., a medical condion) should be engraved on the ID. Important: By accepng service with MedicAlert Foundaon, you authorize MedicAlert to release all informaon about you in emergencies. MedicAlert relies upon the accuracy of the informaon 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 informaon 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 representave 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 Foundaon is a 501(c)(3) nonprofit organizaon. ©2015 All rights reserved. MedicAlert® is a U.S. registered trademark and service mark of MedicAlert Foundaon Internaonal. 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 Size q 5” q 5½” q 6” q 6½” q 7” q 7½” q 8” q 8½” q 9” When selecng size, please measure your wrist snugly and add ½”. Select Bracelet Size q 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 Size q S (5”-6”) q M (6.5”-8”) q A751 q A156 (pete) q A491 (lg) q A657 q A658 q A739 q A740 (lg) q A659 q 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 A126 q 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 leer or statement from the individual requesng the sponsorship or a copy of a state or federal government public assistance program card. For more informaon please visit our website at www.medicalert.org/donate/sponsored-membership