Sample of an Emergency Information Card

Name of Childcare/Center	Caregiver Name:
Address:	Phone:
Child's Name
Date of Birth:	Home Phone:
Address:
Mother's Name:	Work Phone:
Father's Name:	Work Phone:
Emergency Contact:	Daytime Phone:
Child's Doctor:	Phone:
Medical Card #:
Allergies:
Medical Conditions:
Medications:

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