PHILIPPINE RED CROSS

Laguna Chapter

DECLARATION OF MEMBERS

Contact Person & Number Effectivity: 12:00 noon from the date of registration and date of expiration

Name of Agency / School File your claims within 30 days from the date of accident

School Address NO. OF MEMBERS :

Official Receipt No. VALID DATE (mm/dd/yy) : EXPIRY DATE (mm/dd/yy) :

BIRTHDAY Date of Relationship to Emergency Person

No LAST NAME FIRST NAME MIDDLE NAME AGE GENDER BRGY. MUNICIPALITY PROVINCE MOBILE NO. MAAB Number Validity Date Guardian Contact #
(mm/dd/yy) Recruitment RCY Member

10

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