Emergency Contact Information

In an emergency, it is easy to forget even the most well known information. That is why it is crucial for you to complete the information in this form for each member of your household. Then, give copies to each member of your household who is old enough to use them. Post a copy by each telephone and in easy-to-find places in your home, car and workplace. Be sure to update the information often. Also, make copies for anyone who has contact with you and your family, such as relatives, babysitters, caretakers, neighbors and teachers.

Emergency telephone numbers: 9 1 1 (nine, one, one)

Emergency transport system
(if the 9-1-1 system is not available in your area):

Post the poison center telephone number by every telephone in your home. To locate the nearest poison center call: (202) 362-7217 or write to:

American Association of Poison Control Centers
3201 New Mexico Avenue, NW, Suite 310
Washington, DC 20016

Poison control:

Physician's name/telephone:

Hospital emergency room:

Police:

Fire:

Other:

This information is about:

Child's full name:

Date of birth:

Height: at last physical in:

Weight: at last physical in:

Home address:

Directions to home:

Home telephone:

Allergies:

Medical conditions:

Current medications:

Child's physician:

Child's dentist:

Medical insurance company:

Policy holder's name:

Policy number: Group number:

Immunizations and dates:

MMR:	Hib:
DPaT:	Tetanus booster:
OPV:	Chickenpox:
IPV:	Hepatitis:

Emergency contacts:

Contact person #1:

Name:

Relationship:

Work or home address:

Telephone:
Home:
Work:

Contact person #2:

Name:

Relationship:

Work or home address:

Telephone:
Home:
Work:

Contact person #3:

Name:

Relationship:

Work or home address:

Telephone:
Home:
Work:

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