Checklist: Emergency Info

Make this important worksheet the first one you print out. (Then print the rest! Just this one first.) After you fill in all the info (doctor’s number, emergency contacts, insurance info, etc.), make copies and post by every phone in your home. Though you may never need it (that’s the hope!), you’ll rest better knowing that if ever there is an emergency, you or whoever’s in charge will easily be able to find all the necessary info.

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Emergency Info:

[ ] Mom’s work phone:

[ ] Mom’s cell phone:

[ ] Dad’s work phone:

[ ] Dad’s cell phone:

[ ] 911

[ ] Poison control: 1-800-222-1222

[ ] Police department:

[ ] Fire department phone:

[ ] Other local/appropriate emergency numbers:

[ ] Child’s doctor:

[ ] Doctor phone:

[ ] Child’s chart number: (if appropriate)

[ ] Child’s dentist:

[ ] Dentist phone:

[ ] Preferred hospital:

[ ] Hospital phone:

[ ] Address:

[ ] Directions:

[ ] Emergency contact 1:

[ ] Phone number(s):

[ ] Relation:

[ ] Emergency contact 2:

[ ] Phone number(s):

[ ] Relation:

[ ] Closest neighbor:

[ ] Phone number(s):

[ ] Address:

[ ] Home address:

[ ] Closest major intersection:

[ ] Mom’s full name:

[ ] Dad’s full name:

[ ] Child’s full name:

[ ] Child’s date of birth:

[ ] Any allergies, medications or special conditions:

**
[ ] **Insurance provider:

[ ] Insurance provider phone:

[ ] Insured name and ID:

[ ] Group ID:

[ ] Policy ID:

[ ] Release: I, _______________, authorize any licensed physical, dentist or hospital to give _______________, born _______________, all necessary emergency medical services.

Sign:                             Date: