Indiana Code Title 12. Human Services § 12-9.1-6-6

(1) The program participant's name.

(2) A photograph of the program participant.

(3) The contact information for not more than two (2) emergency contacts for the program participant.

(4) The program participant's medical information, including medical conditions, recent surgeries, allergies, and current medications.

(5) The program participant's hospital preference.

(6) The contact information for not more than two (2) health care providers of the program participant.

(7) The date the program participant completed the form.

(1) A statement that the program acts as a facilitator only, and that all information supplied on the medical information form is the sole responsibility of the program participant.

(2) A statement that the program participant supplies the medical information voluntarily, and that the program participant authorizes the disclosure and use of the medical information for the purposes described in section 9(b) of this chapter.