GUARDIANSHIP DISASTER PLAN Date of Plan: Attach 2" x 2" Photograph Here WARD INFORMATION Name: Address: Date of Birth: Sex: Identifying Scars/Marks: Aliases: Social Security Number: Additional Insurance: Allergies: Medications: Disabilities/Impairment/Diagnosis: Living Will: Yes (attach copy) Physician's Name: Address: No Telephone Number: Case Number: Telephone Number: Eye/Hair Color: Height/Weight: Race: Religion: Medicare Number: Where will Ward be relocated in the event of an evacuation: Address: Telephone Number: GUARDIAN INFORMATION Name: Address: Cell Phone: Home Phone: ATTORNEY INFORMATION Other: Name: Telephone Number: American LegalNet, Inc. www.FormsWorkFlow.com