SPONSORED
MEMBERSHIP FORM
MEDICALERT MEDICAL IDS
Please choose one ID.
q A605
PROOF OF HARDSHIP
q A734
Proof of hardship is required for approval of MedicAlert sponsored membership.
This proof can be supplied in the form of a letter or statement from the individual
requesting the sponsorship or a copy of a state or federal government public
assistance program card. For more information please visit our website at
www.medicalert.org/donate/sponsored-membership
q S (5”-6”) q M (6.5”-7.5”) q L (8”-9”)
CLASSIC STRETCH BAND
q A843
INFO FOR PERSON WEARING THE MEDICAL ID
q A840
q A841
q A602
q A604
q A603
q A601
q A600
DOG TAGS
(30” beaded chain necklace)
Not recommended for children under 12.
FIRST NAME MIDDLE NAME
MAILING ADDRESS
PHONE
CITY
LAST NAME
STATE
EMAIL ADDRESS
q Male
DATE OF BIRTH
ZIP
EMERGENCY CONTACT NAME
q Female
q A842
Select Bracelet Size
q S (5”-6”) q M (6.5”-8”)
REFLECTIVE SPORTS BANDS
q A795
(HEART)
GENDER
EMERGENCY CONTACT EMAIL
EMERGENCY CONTACT PHONE #1
PHONE #2
PRIMARY PHYSICIAN
PHYSICIAN PHONE
q A832
q A833
q A837
q A831
q A834
q A830
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”
PENDANTS
MEDICAL CONDITIONS / ALLERGIES / MEDICATIONS / DEVICES
MEDICAL CONDITIONS & DEVICES:
q A829
SILICONE COMPETE BRACELETS
q A794
(limited engraving
space)
q A823
q A824
q A827
q A828
q A826
SWEETHEART CHARM BRACELET
ALLERGIES: List all known food, drug or other allergies
q A825
q A096
Select Bracelet Size
q S (6”) q M (6.75”) q L (7.5”)
MEDICATIONS: List all medications and dosages, including inhalers
SILICONE PLAY BRACELETS
q A655
q A664
(limited engraving
space)
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 additional critical information (e.g., a medical condition) should be engraved on the ID.
Important: By accepting service with MedicAlert Foundation, you authorize MedicAlert to release all information
about you in emergencies. MedicAlert relies upon the accuracy of the information 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 information 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 representative 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.)
q A156 (petite)
q A751
q A491 (lg)
q A656
q A657
q A658
q A739
q A740 (lg)
q A126
q A659
q A091 (lg) q A729 (lg)
Select Bracelet Size
q A661
q 5” q 5½” q 6” q 6½”
q 7” q 7½” q 8” q 8½” q 9”
When selecting size, please measure your
wrist snugly and add ½”.
SHOE TAGS
STAINLESS STEEL BRACELETS
Mail completed application to: MedicAlert Foundation, PO Box 21009, Lansing, MI 48909-1009 or Fax to: 209.669.2495
MedicAlert Foundation is a 501(c)(3) nonprofit organization. ©2015 All rights reserved. MedicAlert® is a U.S. registered trademark and service mark of MedicAlert Foundation International.