Emergency Info Sheet

Emergency Information Sheet

Child/Children’s full name(s):___________________________________________________
________________________________________
Date of birth: ____________________________

_________________________________________

Home address: _____________________________________________________________________________________________________

Closest major intersection:______________________________________________________

Any allergies, medications or special conditions:_____________________________________________________________________

_________________________________________________________________________________________________________________

Police Department: ____________________________________

Fire Department: ______________________________________

Poison Control:1-800-222-1222

Other Emergency #: _____________________________________

Insurance provider: __________________________________________Insured name and ID: __________________________________ Group ID: _________________ Policy ID: _________________

Insurance provider phone: ________________________

Mom’s full name: __________________________________________
Preferred phone: _______________________________________

Other phone: __________________________________________

Dad’s full name: __________________________________________
Preferred phone: ________________________________________

Other phone: __________________________________________

Emergency contact 1: __________________________________________Phone: _______________________________________________

Relation: ______________________________________________

Emergency contact 2: __________________________________________Phone: _________________________________________________

Relation: _______________________________________________

Pediatrician: __________________________________________Address: _________________________________________________________________________

Directions:_________________________________________________________________________

Pediatrician phone: ______________________________

Preferred hospital: __________________________________________Address:__________________________________________________________________________

Directions______________________________________________________________________________________________________

Hospital phone: __________________________________

Dentist: __________________________________________Dentist phone: ___________________________________

Neighbor(s): __________________________________________________

Address:_______________________________________________________________________

Phone: __________________________________________