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SAMPLE CHILD CARE- CHILD INFORMATION …

1 SAMPLE CHILD care - CHILD INFORMATION form for emergency / disaster preparedness INSTRUCTIONS TO PARENTS: (1) Complete all items on this form . Sign and date where indicated. (2) If your CHILD has a medical condition, which might require emergency medical care , complete the form . If necessary, have your CHILD s health practitioner review that INFORMATION . NOTE: THIS ENTIRE form MUST BE UPDATED ANNUALLY. DATE: _____ When parents cannot be reached, list at least one person who may be contacted to pick up the CHILD in an emergency / disaster : 1. Name _____Telephone (H) _____ (W) _____ Last First _____ Address Street/Apt. # City State Zip Code 2. Name _____Telephone (H) _____ (W) _____ Last First _____ Address Street/Apt.

1 SAMPLE CHILD CARE- CHILD INFORMATION FORM for EMERGENCY/DISASTER PREPAREDNESS . INSTRUCTIONS TO PARENTS: (1) Complete all items on this form.

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