EMERGENCY INFORMATION FORM


EMERGENCY INFORMATION FORM
A Safe Homes, Safe Schools, Safe Shuls Initiative. Please fill out one form for every family member and place it in a prominent location.
NAME:		Date Card Completed:
ADDRESS:		Telephone:
EMERGENCY CONTACTS:		Allergies to Meds:
1)
2)
3)		DATE OF BIRTH:
DOCTOR'S NAME:		MAJOR ILLNESSES:
DOCTOR'S PHONE:
HEALTH CAREPLAN:



MEDICARE #:		OTHER:

CURRENT MEDICATIONS	DOSAGE STRENGTH	HOW OFTEN TAKEN	WHEN TAKE







MEDICATION	STORED WHERE