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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, 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

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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