Emergency Information Form
In an emergency, it's easy to forget even the most well-known information. That is why it's vital for you to fill out the information in this form for each person in your home. Then give copies to each person in your household. And post all copies in easy-to-find places in your home, car, or workplace. Update the information often.
Also make copies for nonresident relatives, babysitters, caretakers, neighbors, teachers—anyone who has contact with you, or who is sometimes responsible for your children. And make copies for any adults in your home who have a disability or who are older.
If you own a smartphone, put two different contacts in your phone under ICE for "in case of emergency." Then the emergency room staff can call your contacts if you're not able to communicate. Examples could be ICE-Mom or ICE-Husband to identify your contact. Newer smartphones have apps that you can download to make this information easier to access. But don't rely on your smartphone. It may be out of power, overlooked, or not with you at the time. It's still vital to have additional copies of this form.
911
Or use the number for your local emergency transport system (if the 911 system isn't available in your area):
|
_____________________________________________________________
|
Post the poison control center phone number by every phone in your home and add the phone number to all cell phones. 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
|
|
Healthcare provider's name and telephone
|
|
Hospital emergency room
|
|
Police
|
|
Fire
|
|
Other
|
This information is for
|
Person's full name
|
|
|
Date of birth
|
|
|
Height
|
at last physical on:
|
|
Weight
|
at last physical on:
|
|
Home address
|
|
Directions to home
|
|
Home phone/cellphone
|
|
Allergies
|
|
Health conditions
|
|
Current medicines
|
Emergency contacts
|
Contact person #1
|
|
|
|
Name
|
|
Relationship
|
|
Work or home address
|
|
Phone:
|
Home
|
Work
|
|
Contact person #2
|
|
Name
|
|
Relationship
|
|
Work or home address
|
|
Telephone
|
Home
|
Work
|
|
Contact person #3
|
|
Name
|
|
Relationship
|
|
Work or home address
|
|
Phone
|
Home
|
Work
|
|
Additional instructions
|