Emergency Tag Info

Please fill out the following information as accurately and completely as possible in order to process your Emergency Info Tag. Please read my Privacy Statement if you have concerns.

Motorcycle accidents can be very devastating, and having a waterproof, colorful tag to attract the attention of emergency personnel could save a life. Accidents do happen. We don't like to think it will happen to us, or that we might be injured, but it's best to be prepared. The Info Tag is approximately 4½" x 3", laminated, and easily fits in the “Emergency Info” pocket of your new tank bag. It contains pertinent information about you on one side, emergency contacts on the other, and is designed to be noticed. Please feel free to fill out another separate form for members of your family that are frequent passengers of yours.

 

Required Fields *

 

PERSONAL INFORMATION
*Full Name
*Street Address
Address (cont.)
*City, State , 
*Zip Code  
*Date of Birth Format as MM/DD/YYYY
*E-mail Address

 

MEDICAL INFORMATION: (Please don't put carriage returns in these fields. I will format the text when I print the tag. Separate lists with commas or semicolons and spaces.)
Primary Physician's Name
Phone Number
Blood Type
Medicine Allergies
(Penicillin, etc.)
Medical Conditions
Insurance Company
Policy / Group #
Additional Information
(Medications, etc.)

 

EMERGENCY CONTACTS: Please list up to three contacts. Each contact can have up to four phone numbers.
*Emergency Contact Name #1
Relationship
*Phone #1 Number / Type
Phone #2 Number / Type
Phone #3 Number / Type
Phone #4 Number / Type
Emergency Contact Name #2
Relationship
Phone #1 Number / Type
Phone #2 Number / Type
Phone #3 Number / Type
Phone #4 Number / Type
Emergency Contact Name #3
Relationship
Phone #1 Number / Type
Phone #2 Number / Type
Phone #3 Number / Type
Phone #4 Number / Type
Primarily ride as Driver   Passenger