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CARETAKER EMERGENCY PLAN

 

Our home address is:  ______________________________________________

 

Our Children
 

 

Child:________________________________________________________________

Date of birth:________________________________________________________

 

Child:________________________________________________________________

Date of birth:________________________________________________________

 

Child:________________________________________________________________

Date of birth:________________________________________________________

 

Doctor Information

 

Our children's primary physician:___________________________________________________________

Name of clinic:______________________________________________________

Office address:_____________________________________________________________

Office phone number:_____________________________________________________________

Medical Insurer/Health Plan:_________________________________________________________________

Plan policy #:________________________________________________________

Name and address of closest hospital:_____________________________________________________________

 

Medical Conditions


Our children have the following medical conditions and require the following instructions: ________________________________________________________________________________________________________________________________________________

Medical conditions: ________________________________________________________________________________________________________________________________________________

 

 

Medical allergies: _______________________________________________________________________

 

Allergies to food: _______________________________________________________________________

Prescriptions or treatments:__________________________________________________________

 

Conditions for which children are currently being treated:______________________________________________________________

 

List of medications, dosage and time to be administered:________________________________________________________________________________________________________________________________

 

Any other significant medical information:__________________________________________________________

________________________________________________________________________

 

Dental Information

Dentist’s Name:________________________________________________________________

Name of Dental Clinic:________________________________________________________________

Dental office address:_____________________________________________________________

Dental Insurer:______________________________________________________________

Policy #: ____________________________________________________________

 

Parent Contact Information

Parent’s Name:________________________________________________________________

Cell Phone:______