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HOME | ABOUT EAN | EAN SERVICES | AFFILIATES | CREDIT UNION MEMBERS | JOIN EAN

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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.

* = Required Fields

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

Family Member 1
* Member Name:
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Evening Phone:
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Medical Conditions:
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Donor?
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Family Member 2
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Medical Conditions:
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Family Member 3
Family Member #3 Name:
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Family Member 4
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Emergency Contact #1
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Emergency Contact #2
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Emergency Contact #3
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Emergency Contact #4
Contact Name:
Address
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Evening Phone:
Cell Phone:
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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."

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• Kosair Shrine of Louisville, KY
• Brain Injury Alliance of KY
• Kentucky Bankers Association
• Ford Plant in Louisville, KY
• Owen Funeral Home of Louisville, KY