Emergency Information Form

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, distribute copies to each member of your household. Also, post all copies by each telephone and in easy to find places in your home, automobile, or place of business. Be sure to update the information frequently.

Also, make copies for non-resident relatives, babysitters, caretakers, neighbors, teachers -- anyone who has contact with you or who is periodically responsible for your children (or any disabled or older adults in your home).

Emergency Telephone Numbers:

9 1 1 (nine, one, one)

Emergency Transport System (if 9-1-1 system is not available in your area)

Post the poison center telephone number by every telephone in your home. The national, toll-free poison control center locator number is: 800-222-1222. From here, you will be automatically redirected to the nearest Poison Center in your area.

Poison control

Physician's name/telephone

Hospital emergency room

Police

Fire

Other

This information is

Person'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

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

Additional Instructions:

Emergency Information Form

Emergency Telephone Numbers:

9 1 1 (nine, one, one)

This information is

Emergency Contacts:

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