Home Address:__________________________________________________________________

Directions to our home:________________________________________________________

Home Phone:____________________________ Work Phone:____________________________

Cell Phone(s):_________________________ Pager #:_______________________________

Medical Emergency Contact(s):__________________________________________________

Police Department:_____________________ Fire Department:_______________________

Gas Company:___________________________ Electric Company:______________________

Taxi Service (leave money in case of emergency):_______________________________

Poison Control:________________________ Pediatrician:__________________________

Pediatrician Phone:____________________ Address:_______________________________

Hospital:______________________________ Address:_______________________________

Hospital Phone:________________________ Other Important Phone #s:______________

HEALTH INFORMATION

Company:_____________________ Group #:__________________ ID #:_________________


NEIGHBOR INFORMATION

Names & phone #s of neighbors:_________________________________________________


CHILD'S INFORMATION

Name:__________________________________ Date of Birth:_________________________

Height:________Weight:________ Allergies_______________________________________

Foods Not Allowed:_____________________________________________________________

Medical Condition(s):__________________________________________________________

Medications:___________________________ Dosage:________________________________


Name:__________________________________ Date of Birth:_________________________

Height:________Weight:________ Allergies_______________________________________

Foods Not Allowed:_____________________________________________________________

Medical Condition(s):__________________________________________________________

Medications:___________________________ Dosage:________________________________