This emergency contact form provides important contact information for a child, including their name, date of birth, and contact details for parents/guardians and an alternate emergency contact. It also lists contact details for local police, fire, and poison control services as well as the child's doctor and the address, nearest cross streets, and nearest hospital in case of a life-threatening emergency.

1. EMERGENCY CONTACT FORM
For LIFE THREATENING EMERGENCIES: CALL 911
POLICE: _____________________
FIRE: _____________________
POISON CONTROL CENTER: _____________________
Child’s name: _________________________________________
Child’s date of birth: _____________________
Parent/Guardian Name: __________________________________
Parent/Guardian Phone: _____________________
Parent/Guardian Name: __________________________________
Parent/Guardian Phone: _____________________
Alternate Emergency Contact Name: _________________________
Alternate Emergency Contact Phone: _____________________
Doctor Name: ________________________________________
Doctor Phone: _____________________
The address here is: __________________________________
The nearest cross streets are: ____________________________
The nearest hospital is: __________________________________
NOTE: As of (date) ________, the child is taking the following
medications: __________________________________
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