Kanawha Valley Village People (KVVP) of West Virginia – www.kvvp.org
KVVP, Box 60076,Charleston, WV, 25303, 304.767.5774
NAME: (last name, first name, middle initial): Today’s Date:
Street Address: Date of birth Age
City, State, ZIP: Height Weight...
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Kanawha Valley Village People (KVVP) of West Virginia – www.kvvp.org
KVVP, Box 60076,Charleston, WV, 25303, 304.767.5774
NAME: (last name, first name, middle initial): Today’s Date:
Street Address: Date of birth Age
City, State, ZIP: Height Weight
Your Phone (H-Home, C-Cell, W-Work):
Emergency Contact (name & relationship) and Phone (H-Home, C-Cell, W-Work):
MEDICAL ALERT (i.e. diabetes, epilepsy, Alzheimer’s,Parkinson’s, asthma, deafness, etc.):
Next of Kin and Phone (H-Home, C-Cell, W-Work):
Power of Attorney If you have one, who is it?:
Where is POA filed?:
POA Contact Phone (H-Home, C-Cell, W-Work):
Advance Directive, if you have an Advance Directive, where is it?:
DNR (Do Not Resuscitate), if you have a DNR order, where is it?:
SOCIAL HISTORY (i.e. smoker, snuff, alcohol, recreational drugs):
Implanted medical devices (i.e. such as pacemaker, pain pump, ICD (automatic defibrillator, insulin pump, TENS unit, etc. (Important if
diagnosis requires MRI):
VACCINATIONS: Pneumoni
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