This offer for free membership is made possible by a generous grant provided by Amie’s Place Foundation. To learn more about Amie’s Place, visit www.amiesplacefoundation.org

Keeping Families ConneCted Free memberships

for qualified pet owners

MedicAlert Foundation® is a 501(c)(3) nonprofit organization. ©2013 MedicAlert Foundation. All rights reserved. MedicAlert® is a U.S. registered trademark and service mark of MedicAlert Foundation International. 615636

medicalert® and amie’s place: Committed to Keeping Families Together

Through a generous grant from Amie’s Place Foundation, MedicAlert Foundation® is pleased to offer FREE enrollment and provide its live 24/7 emergency services and medical ID’s to qualified pet owners who are confined by illness or disability and need to be sure their pets are taken care of should they face a medical emergency or other crisis.

Amie’s Place Foundation is dedicated to supporting people who are at risk of losing their pets at times of crisis only because no one is there to help them.

MedicAlert Foundation is the nonprofit leader in emergency medical information and identification services. With a 56-year history of providing peace of mind to our members in times of need, together with Amie’s Place Foundation, we are continuing that tradition of care and service so that members can be reunited with all their loved ones, including their pets.

MedicAlert Founder, Dr. Marion Collins, with his family

Membership benefits through Amie’s Place Foundation Grant

Approved applicants will receive a 3-year membership (and automatically qualify for a 3-year renewal thereafter) and a medical ID, custom-engraved with a member number, critical medical information, and the MedicAlert® live 24/7 emergency response number. This information gives first responders immediate access to the member’s medical records and alerts our Contact Center to reach the member’s backup pet caregiver. Benefits include:

• MedicAlert medical ID • Live 24/7 Emergency Response Services • Live 24/7 Family & Physician Notification Service • Live 24/7 Alternative Caregiver Notification Service • EMIR® (Emergency Medical Information Record) • Emergency Wallet Card • Window decal announcing your home has a pet inside

that needs care

To be eligible for sponsored membership through the Amie’s Place Foundation grant, individuals are qualified through the following means:

1. Have one (or more) pet(s)2. A completed enrollment form or enrollment by phone

with our Contact Center representatives3. A brief statement of need based on disability, illness,

limited mobility or risk of losing pets due to hospitalization or extended treatment outside of the homehe inability to afford the membership fee, renewal or reorder

program limitations As a nonprofit organization, MedicAlert Foundation reserves the right to modify this program to assure fairness in its implementation as well as adequate funding. Although MedicAlert Foundation’s intent is to extend sponsored membership to anyone who needs our service but cannot afford it, the number of memberships sponsored annually must be limited to the resources available from grant funding for this program.

mail to: MedicAlert Foundation 2323 Colorado Avenue, Turlock, CA 95382 phone: (800) 432-5378

PERSoNAL INFoRMATIoN

EMERgENCy CoNTACTS Only contacts listed can update member’s record.

MEDICAL CoNDITIoNS / ALLERgIES / MEDICATIoNS (FoR MEMBER)

PET INFoRMATIoN

STATEMENT REqUESTINg SPoNSoRSHIP

SIgNATURE

PREvIoUS/CURRENT MEDICALERT MEMBER IF yES, ENTER MEMBER NUMBER

FIRST NAME MIDDLE NAME LAST NAME

MAILINg ADDRESS CITy STATE zIP

PHoNE EMAIL ADDRESS

DATE oF BIRTH gENDER

PRIMARy EMERgENCy CoNTACT RELATIoNSHIP

EMERgENCy CoNTACT’S PHoNE SECoNDARy PHoNE

SECoNDARy EMERgENCy CoNTACT RELATIoNSHIP

EMERgENCy CoNTACT’S PHoNE SECoNDARy PHoNE

PRIMARy PHySICIAN PRIMARy PHySICIAN PHoNE

HEALTH INSURER gRoUP PLAN # INSURER MEMBER #

PET EMERgENCy CoNTACT PHoNE NUMBER

PET NAME & PET TyPE (IE: FIDo/Dog) PET NAME & PET TyPE (IE: FIDo/Dog)

PET NAME & PET TyPE (IE: FIDo/Dog) PET NAME & PET TyPE (IE: FIDo/Dog)

q yes q No

q Male q Female

important: By accepting membership in MedicAlert Foundation you authorize MedicAlert to release all medical and other confidential information about you, in emergencies, and to other healthcare personnel you designate. MedicAlert relies upon the accuracy of the information members supply. Member therefore agrees to defend, indemnify and hold MedicAlert (including its employees, officers, directors and agents) harmless from any claim or lawsuit brought by member or others for injury, death, loss or damages arising in whole or in part out of member’s provision of incomplete or inaccurate information to MedicAlert.

Signature of member Date

ENRoLL & SELECT PRoDUCT

Enrollment in MedicAlert® membership includes establishment of your MedicAlert emergency medical information record, a MedicAlert emergency member card, secure online access to your MedicAlert records, and the MedicAlert emergency response center on call 24 hours a day, seven days a week to help you at any time.

medicalert membership Fee

seleCt YoUr prodUCt (See product details to the right)

total

FREE

FREE

FREE

ID Engraving: In an emergency, response personnel need to be aware of your critical medical information in order to treat you correctly. your MedicAlert® ID will be engraved with your membership number and our 24-hour emergency response number to enable responders to assist you immediately.

please note: once your MedicAlert ID has been engraved and shipped, there will be an additional charge for any changes requested. ID engraving is personalized to individual members and cannot be transferred to another individual, altered, sold, or returned. To help assure you receive thorough, accurate treatment, the condition our trained staff deems most relevant to your medical needs in an immediate emergency treatment will be engraved on your ID. No refunds will be issued.

MEDICALERT® MEDICAL IDS

stainless steel pendants(26” or 30” chain necklace)

q A721 (RED)

q A738 (BLACK)

q A722

q A601

q A600

q A156 (PETITE)q A492 (SMALL)

q A126 (RED - SM)q A091 (RED - Lg)

q A654 (LT BLUE - SM)

q A657 (gREEN - SM)

q A658 (PINK - SM)

q A739 (BLACK - SM)q A740 (BLACK - Lg)

q A660 (LILAC - SM)

q z102 (PURPLE - SM)q z101 (PURPLE - Lg)

q A655 (BLUE - SM)

q A751 (WHITE - SM)q Axxx (WHITE - Lg)

q A656 (oRANgE - SM)

q A491 (LARgE)

stainless steel braCelets(Lengths available: 5”, 5½”, 6”, 6½”, 7”, 7½”, 8”, 8½”, and 9”)When selecting size, please measure your wrist snugly and add ½”.

IDs in this box shown at actual size.

stainless steel braCelets(Lengths available: 5”, 5½”, 6”, 6½”, 7”, 7½”, 8”, 8½”, and 9”)When selecting size, please measure your wrist snugly and add ½”.

dog tags(30” beaded chain necklace)

shoe tag

q A661

q Home q Cell q Work

Free Membership Application Form

615636