Common Childhood Injuries and Poisonings
Emergency Information Form
In an emergency, it is easy to "forget" even the most well-known information. That is why it is crucial for you to complete the information in this form for each member of your household. Then, distribute copies to each member of your household. Also, post all copies by each telephone and in easy to find places in your home, automobile, or place of business. Be sure to update the information frequently.
Also, make copies for non-resident relatives, babysitters, caretakers, neighbors, teachers - anyone who has contact with you or who is periodically responsible for your children (or any disabled or elderly persons in your home).
Emergency Transport System
(if 9-1-1 system is not available in your area)
Post the poison center telephone number by every telephone in your home. The national, toll-free poison control center locator number is: 1-800-222-1222. From here, you will be automatically redirected to the nearest Poison Center in your area.
| Poison control |
| Physician's name/telephone |
| Hospital emergency room |
| Police |
| Fire |
| Other |
| Person's Full Name |
| Date of birth |
| Height |
at last physical in: |
| Weight |
at last physical in: |
|
| Home Address |
| Directions to Home |
| Home Telephone |
|
| Allergies |
|
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| Medical Conditions |
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| Current Medications |
|
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| Contact Person #1 |
| Name |
| Relationship |
| Work or Home Address |
| Telephone: |
home |
work |
|
| Contact Person #2 |
| Name |
| Relationship |
| Work or Home Address |
| Telephone: |
home |
work |
|
| Contact Person #3 |
| Name |
| Relationship |
| Work or Home Address |
| Telephone: |
home |
work |
|
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Click here to view the
Online Resources of Common Childhood Injuries & Poisonings
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