This sheet of paper could save your life.   In case of a serious accident the following information can be vital to saving your life.  Please copy, fill in the information and put in it your billfold or in a place where it will be readily found in case you are seriously injured.

Take care and Ride Safe.

http://www.lazyrider.com

Name:________________________________Age__ ___DOB ___________ SSN _______/_____/______________

Address: ______________________________________________________________________________________

City: _______________________________________           State _______________                       Zip: _____________

In case of accident, notify: __________________________________________ Phone: _________________________

Home Phone No, _____________________ Work No. ______________________ Email: ________________________

Blood Type: ____ Previous Transfusion Reaction? _____ If Yes,   Explain Below ________________________________

Allergies to Medications? ____ If Yes,  Which Med.? _____________________________________________________

Contact Lenses? ______ Dentures?________ Diabetic? ________ Epileptic ________

Other Import Info. ________________________________________________________________________________

Heart Condition? _________ Previous Heart Attack?___________ H B Pressure: ______________________________

Other Medical Conditions (list)_______________________________________________________________________

Family Dr.___________________  Phone:_______________________