GlobalAssist™ Deployment

Nombre de pila

Apellido

Correo electrónico

Teléfono

Relationship to person(s) requiring assistance

GlobalAssist Membership No.

(if an existing GlobalAssist™ member)

Nombre de pila

Apellido

Date of birth

Teléfono

Correo electrónico

Number of Persons Requiring Assistance:*

Country of Residence

Additional Information

e.g. Overview of nature of incident / Injuries / Existing Health Conditions / Additional persons requiring assistance

Current Location

City

State/Province

Zip/Postal

País

GPS/Location Coordinates:

Share your location with what3words:

Additional Information

e.g. Location / Landmarks / Specific Instructions / Nature of Emergency / Injuries Sustained / Existing Medical Conditions

Please submit any photographs that would assist the GlobalAssist™ deployment team:

Tamaño máximo del archivo: 5MB

e.g. Images of injuries / Location / Landmark

Captcha

GlobalAssist™ Deployment.