EMERGENCY INFORMATION

The St. Clair

1111 Bering Drive

Houston, TX  77057-2301

PLEASE COMPLETE THE FOLLOWING FORM FOR OUR OFFICE FILE:

DATE____________________________     UNIT #_________________________

Name:____________________________     Home phone_____________________

Office phone_____________________

Cellular        _____________________

Mailing Address_____________________  E-mail address

________________________            ___________________________

_________________________

Please list all occupants (If children, show age)

____________________________________   ________     ________________________

____________________________________   ________     ________________________

____________________________________   ________     ________________________

In case of emergency, would each occupant be able to walk up or down at least three

(3) flights of stairs?  YES_______  NO_______.  If no, list manner of disability above,

Following each name.

Who should we contact in case of an emergency?

Name                                                               Relationship                              Phone #

__________________________________    ________________________   __________

__________________________________    ________________________   __________

__________________________________    ________________________   __________

Name of personal physician:_____________________________ Phone #_____________