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: 1-800-222-1222          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:__________________________________ Birthdate:____________ Bedtime:________

Height:________Weight:________ Allergies_______________________________________

Foods Not Allowed:_____________________________________________________________

Medical Condition(s):__________________________________________________________

Medications:___________________________ Dosage:________________________________

Name:__________________________________ Birthdate:____________ Bedtime:________

Height:________Weight:________ Allergies_______________________________________

Foods Not Allowed:_____________________________________________________________

Medical Condition(s):__________________________________________________________

Medications:___________________________ Dosage:________________________________