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Diseases & Conditions : Common Childhood Injuries and Poisonings

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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 nonresident 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: 800-222-1222. From here, you will be automatically redirected to the nearest Poison Center in your area.

Poison control

 

Doctor's name/telephone

 

 

Hospital emergency room

 

Police

Fire

Other

 

 

 

This information is

Person's full name

 

Date of birth

Height

Date of last physical

 

Weight

Date of last physical

 

 

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