Kosair Shrine Members, Join EAN Now!

* When joining EAN on this page, under this organization, a portion of the proceeds are donated to this organization.

Please fill in ALL of the information below. After you have filled in the online form please click the "submit" button at the end of the form to submit your online registration information and then follow the steps to process payment for your new EAN membership.

How this program works:
1. Fill out all of the information below including the the contacts at the bottom of this form/page. We suggest your first contact be immediate family, husband, wife, etc.
2. Submit the form by hitting the submit button below and follow the steps to process payment for your new memebership.

Additional information about the program and the additional steps you should follow will be given to you after payment is process for the new membership.

By Phone?
If you would prefer to join over the phone, call 1-800-769-5019 and we will be glad to help you.

* = Required Fields

REGISTRATION FORM
Type of Registration (Please enter "individual" or "family".):

Family Member 1
* Member Name:
* Address:
* City:
* State:
* Zip Code:
* Daytime Phone:
Evening Phone:
Dealership:
Salesperson:
Date:	Year:	Make:	Model:
Cell Phone:
* Email Address:
Blood Type:
Medical Allergies:
Medical Conditions:
Medical Information:
Donor? (Please put "yes" or "no):

Family Member 2
Family Member #2 Name:
Blood Type:
Medical Allergies:
Medical Conditions:
Medical Information:
Donor? (Please put "yes" or "no):

Family Member 3
Family Member #3 Name:
Blood Type:
Medical Allergies:
Medical Conditions:
Medical Information:
Donor? (Please put "yes" or "no):

Family Member 4
Family Member #4 Name:
Blood Type:
Medical Allergies:
Medical Conditions:
Medical Information:
Donor? (Please put "yes" or "no):

Emergency Contact #1
* Contact Name:
Address
City:	State:	Zip:
* Daytime Phone:
Evening Phone:
Cell Phone:
Email Address:
Relationship:

Emergency Contact #2
Contact Name:
Address
City:	State:	Zip:
Daytime Phone:
Evening Phone:
Cell Phone:
Email Address:
Relationship:

Emergency Contact #3
Contact Name:
Address
City:	State:	Zip:
Daytime Phone:
Evening Phone:
Cell Phone:
Email Address:
Relationship:

Emergency Contact #4
Contact Name:
Address
City:	State:	Zip:
Daytime Phone:
Evening Phone:
Cell Phone:
Email Address:
Relationship:

Emergency contacts and medical information can be changed at any time with the customer's written request or by phone or on-line at www.ealertnet.com. I understand the Emergency Alert Network (EAN) or (its assigns) is authorized to release any of the above contact information. EAN will only release medical information to proper authorities. EAN shall not be liable for failure to notify contacts in any instance where emergency service personnnel fails to notify EAN of an incident. EAN shall not be liable if notification to customer or other contacts are unsuccessful after reasonable attempts have been made utilizing all telephone numbers provided by the customer. EAN shall not be liable for medical information if customer fails to supply us with information or does not inform us of any and all changes to medical information. This membership is between EAN and the above members and any third party shall be held "hold harmless."

Please click submit to agree:
"I have read and understand what this service provides."


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