EMERGENCY FORM

EMERGENCY FORM
INSTRUCTIONS TO CLIENT:

(1) Complete all items on this side of the form. Sign and date where indicated.

(2) If your child has a medical condition which might require emergency medical care, complete the back side of the form . If necessary, have your child’s health practitioner review that information.

NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.
CLIENT NAME:*

First NameLast Name
HOME TELEPHONE NUMBER:*

Area CodePhone Number
BIRTH DATE:*

MonthDayYear
Date
HOME ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY CARETAKER NAME:

First NameLast Name
RELATIONSHIP TO CLIENT:
HOME TELEPHONE NUMBER:

Area CodePhone Number
CELL PHONE NUMBER:

Area CodePhone Number
WORK PHONE NUMBER:

Area CodePhone Number
PRIMARY CARETAKER HOME ADDRESS (IF DIFFERENT FORM CLIENTS ADDRESS)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IF CHILD, MOTHER'S NAME (IF DIFFERENT FORM PRIMARY CARETAKER)

First NameLast Name
HOME TELEPHONE NUMBER:

Area CodePhone Number
MOTHER'S EMPLOYER:
EMPLOYER ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOTHER'S HOMES ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IF CHILD, FATHER'S NAME (IF DIFFERENT FORM PRIMARY CARETAKER)

First NameLast Name
HOME TELEPHONE NUMBER:

Area CodePhone Number
CELL PHONE NUMBER:

Area CodePhone Number
WORK PHONE NUMBER:

Area CodePhone Number
FATHER'S EMPLOYER:
EMPLOYER ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF PERSON AUTHORIZED TO PICK UP CLIENT IF NEEDED:

First NameLast Name
RELATIONSHIP TO CLIENT:
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When Primary Caretaker cannot be reached, list at least two persons who may be contacted for an emergency:
1) NAME:*

First NameLast Name
PHONE NUMBER:*

Area CodePhone Number
ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2) NAME:

First NameLast Name
RELATIONSHIP TO CLIENT:
PHONE NUMBER:

Area CodePhone Number
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CLIENT'S PHYSICIAN OR SOURCE OF HEALTH CARE:
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICATIONS CURRENTLY BEING TAKEN BY CLIENT:
DATE OF LAST TETANUS SHOT:

MonthDayYear
Date
ALLERGIES / REACTIONS:
EMERGENCY MEDICAL INSTRUCTIONS
1) SIGNS / SYMPTOMS TO LOOK FOR::
2) IF SIGNS / SYMPTOMS APPEAR, DO THIS:
3) TO PREVENT INCIDENTS:
OTHER MEDICAL PROCEDURES THAT MAY BE NEEDED:
COMMENTS:
NOTE TO HEALTH PRACTITIONER:

IF YOU HAVE REVIEWED THE ABOVE INFORMATION, PLEASE COMPLETE THE FOLLOWING BELOW:
NAME OF HEALTH PRACTITIONER:

First NameLast Name
PHONE:

Area CodePhone Number
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SIGNATURE OF HEALTH PRACTITIONER:

Clear
DATE:

MonthDayYear
Date
ANNUAL UPDATES:
(Initials/Date)
ANNUAL UPDATES:
(Initials/Date)
In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the Program to have you transported to that hospital.
SIGNATURE OF CLIENT/ PARENT/ GUARDIAN:*

Clear
DATE:*

MonthDayYear
Date
Should be Empty:

EMERGENCY FORM

When Primary Caretaker cannot be reached, list at least two persons who may be contacted for an emergency:

EMERGENCY MEDICAL INSTRUCTIONS

NOTE TO HEALTH PRACTITIONER: