
Name:

Date of Birth:

Name:

Date of Birth:

Name:

Date of Birth:


HOME ADDRESS:



HOME PHONE NUMBER:
MOTHER (full name):

Work number, including extension:

Cell number:

FATHER (full name):

Work number, including extension:

Cell number:



(Close relatives living nearby who can be called upon in an emergency; note who has a car.)
1. NAME:

RELATION TO CHILDREN:

HOME PHONE:

CELL PHONE:

CAR?:

2. NAME:

RELATION TO CHILDREN:

HOME PHONE:

CELL PHONE:

CAR?:

3. NAME:

RELATION TO CHILDREN:

HOME PHONE:

CELL PHONE:

CAR?:


(Include neighbors who live nearby and can be called upon in an emergency; note who has a car.)
1. NAME:

RELATION TO CHILDREN:

HOME PHONE:

CELL PHONE:

CAR?:

2. NAME:

RELATION TO CHILDREN:

HOME PHONE:

CELL PHONE:

CAR?:

3. NAME:

RELATION TO CHILDREN:

HOME PHONE:

CELL PHONE:

CAR?:

NAME:

ADDRESS:

PHONE:

NIGHT/EMERGENCY PHONE (if different from above):

AFFILIATED HOSPITAL:


POISON CONTROL: 800.222.1222
LOCAL POLICE PRECINCT:




(If you need to call 9-1-1, this is the script that will get you help most efficiently. Also, always call 9-1-1 from a landline, if at all possible; it makes it easier for emergency services to trace and locate your call and send help quickly:)
"I’m calling because I need ________________________.
The address here is ____________________________
(full address including apartment number).
The cross streets are ___________________ and ___________________.
The phone number here is _________________________."

CHILD:

SCHOOL NAME:

ADDRESS:

PHONE NUMBER:

TEACHER:

CLASSROOM NUMBER

CHILD:

SCHOOL NAME:

ADDRESS:

PHONE NUMBER:

TEACHER:

CLASSROOM NUMBER:
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