Yavapai County Fire Consortium

The following information is to be used only by official agencies (i.e. Sheriff, Fire Department) should I become unable to provide that information.

My name (last name first):

My spouse/partner's name:

My street address:

My phone number:

FIRST: Emergency contact's name (other than partner):

FIRST Emergency contact's phone number(s) :

SECOND: Emergenry contact's name (other than partner):

SECOND Emergency contact's phone number(s):

I do have a Living Will

Yes

No

I do have a Medical Power of Attorney

Yes

No

My emergency contact has access to these documents

Yes

No

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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