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IDAHO DEPARTMENT OF CORRECTION <br /> CRC Inmate Emergency Data Form <br /> Please Print Clearly <br /> Name: IDOC #: <br /> Last, First, Middle <br /> Date of birth: Place of birth: <br /> Marital Status (married, divorced, single): # of Dependents (if any): <br /> Do you have a pending crisis in your family? (yes/no) If yes, explain: <br /> List any special considerations (deaf, non-English speaking, non-reader, etc.) that you have: <br /> What is your religious preference? (optional) <br /> What was your last place of residence? <br /> Address <br /> City, state,zip <br /> What was your most recent occupation? <br /> Did you serve in the military? (yes/no) <br /> If so, branch: Dates of service: <br /> Type of discharge: Vietnam vet? (yes/no) <br /> Persons to be Contacted in Case of an Accident or Emergency <br /> Person #1 Person #2 <br /> Name: Name: <br /> Address: Address: <br /> Home Phone: Home Phone: <br /> Work Phone: Work Phone: <br /> Relationship to you: Relationship to you: <br /> I understand that if there are any changes to this information, it is my responsibility to contact <br /> facility records staff or my case manager at my current housing facility to have this information <br /> updated. <br /> Inmate's Signature Date <br /> 301.04.03.001 <br /> (Last updated 03/13/2017) <br />