Common Childhood Injuries and Poisonings

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 elderly persons 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: 1-800-222-1222. 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 about:

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:

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