Club Member Bene-it - Emergency Alert Network

Save money, protect your home and keep your family safe. With Emergency Alert Network added to your home club plan, EAN works with emergency service personnel to alert family or other significant contacts when an emergency occurs. They also provide emergency personnel with important medical information with your specific medical conditions.

As a member of Emergency Alert Network you can choose up to four people to be contacted in case of any medical or emergency situation. These contacts could include a spouse, parent, friend, or neighbor. EAN’s emergency specialist’s are available 24 hours a day, 7 days a week, 365 days a year. EAN has a secure data base to insure your complete privacy.

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.

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.

* = Required Fields

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:
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):

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 personnel 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.”

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 #2
* 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: