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Emergency Information Form

This document will help you in an emergency. Print out two copies and fill in the blanks. Keep one copy with you, and give one to your spouse or traveling companion. Also, be sure to pack your child's prescription medicines (and bring them along if you have to take your child to a doctor or an emergency room) and a first-aid kit so you can cope with minor medical problems.

My child's personal information

My child's name
Age:
Height and weight:
Address:
Phone:
Social security number:

My child's doctors

My child's doctor at home:
Phone:
If possible, get a referral from your pediatrician before you leave:
Phone:
Address:

My child's health insurance

Be sure to take health insurance ID cards with you, and before you depart, check your policy or call your insurance company to check on coverage when you're away from home.


Company name:
Policy number:
Phone:

My child's emergency contacts

Name:
Relationship
Phone:
Name:
Relationship
Phone:

My child's medical history

Pre-existing conditions:
Allergies to medicines:
Medications (prescription and nonprescription; note exact names and dosages):
Immunization history (attach a vaccination record to this sheet):
Previous hospitalizations, surgeries:
Comments: