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. To locate the nearest poison center call: 202/362-7217 or write
to: American Association of Poison Control Centers, 3201 New Mexico
Avenue, NW, Suite 310,Washington, DC 20016
Poison Control
Doctor's Name/Telephone
Hospital Emergency Room
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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