| REQUESTOR'S NAME:____________________________________________________ RELATIONSHIP TO SERVICE MEMBER:______________________________________ REQUESTOR'S ADDRESS:_________________________________________________ PHONE: (H)____________________________ (W)___________________________ SERVICEMEMBER'S NAME:________________________________________________ MILITARY ADDRESS:____________________________________________________ _________________________________________ PHONE:_____________________ MESSAGE: (Note: These messages are used for EMERGENCIES...You can request presence of service member, or phone call, or notification only in the event of death or serious injury or impending surgery. You may request health and welfare report on service member if there has no been no word from them in 30 days. Please be brief and concise.) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ IN THE EVENT OF DEATH IN THE FAMILY: NAME OF DECEASED: _________________________DATE OF DEATH:____________ RELATIONSHIP TO SERVICE MEMBER:______________________________________ LOCATION OF BODY (HOSPITAL, FUNERAL HOME, CORONER, ETC.)_____________ _____________________________________________________________________ LOCAL POINT-OF-CONTACT & PHONE #:____________________________________ IN THE EVENT OF ILLNESS/INJURY/SURGERY: NAME:_____________________________________ RELATIONSHIP:_____________ DOCTOR:___________________________________ PHONE:____________________ HOSPITAL:_________________________________ PHONE:____________________ LOCAL POINT-OF-CONTACT & PHONE #:____________________________________ HAS PATIENT CONTACTED DOCTOR TO AUTHORIZE THE RELEASE OF THEIR MEDICAL INFORMATION TO AMERICAN RED CROSS? YES NO (Doctor cannot give a statement to confirm the situation to Red Cross without authorization from the patient for release of information.) --------------------------------------------------------------------- |
| RED CROSS MESSAGE Camp Pendelton, CA (760) 725-6877 24-Hour Hotline 1 (800) 951-5600 |
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