Dept. ID #:_________ Date Submitted:______________
Emergency Data Information
Client’s Personal Data
Child’s Name: _______________ , ______________ ____________
(Last) (First) (Middle)
Home Address: _________________________________________________
(Street)
________________ ________ ________ __________
(City) (State) (Zip code) (County)
Home phone #: _____-_____-________
Nickname(s): _________________________________________________
Diagnosis of Disability: _______________________________________________
Responds best when called : _________________________________________
Is Person verbal? _________
If not Describe means of Communication: ____________________________
_________________________________________________
Primary Language: ________________
Is person Ambulatory? _____
If not Describe means of mobility: __________________________________
______________________________________________________
Identifiers
D.O.B. ____________ Sex: _________ Race: ________
Height: ____________ Weight: _________ Skin tone: ________
Hair color: ____________ Style: _________ Facial Hair: ________
Eye color: ___________ Glasses: _________
Distinguishing Marks: _______________________________________________
________________________________________________
________________________________________________
Other Physical
Characteristics:(please explain in detail): _____________________________________
_________________________________________________
_________________________________________________
Describe best way in interact with person: _______________________________
__________________________________________________
__________________________________________________
Identify specific fears or concerns they might have when approached:_________
___________________________________________________
___________________________________________________
Places Client likes to walks off to: ________________________________________
___________________________________________________
___________________________________________________
Medications: (please Explain) _______________________________________________
__________________________________________________
__________________________________________________
Known Allergies: __________________________________________________
__________________________________________________
Cautions: ________________________________________________
________________________________________________
School/work (location,address,times,etc…) ___________________________________________________
__________________________________________________
__________________________________________________
Additional Info: ________________________________________________
__________________________________________________
__________________________________________________
Emergency contacts
In the order to be contacted
Name: _______________ , ______________ ____________
(Last) (First) (Middle)
Address: _________________________________________________
(Street)
________________ ________ ________ __________
(City) (State) (Zip code) (County)
Relationship
To client: ________________________
Home phone #: ____-____-______ Cell #: ____-____-______
Work #: ____-____-______ Misc #: ____-____-______
Name: _______________ , ______________ ____________
(Last) (First) (Middle)
Address: _________________________________________________
(Street)
________________ ________ ________ __________
(City) (State) (Zip code) (County)
Relationship
To client: ________________________
Home phone #: ____-____-______ Cell #: ____-____-______
Work #: ____-____-______ Misc #: ____-____-______
Emergency contacts(cont.)
Name: _______________ , ______________ ____________
(Last) (First) (Middle)
Address: _________________________________________________
(Street)
________________ ________ ________ __________
(City) (State) (Zip code) (County)
Relationship
To client: ________________________
Home phone #: ____-____-______ Cell #: ____-____-______
Work #: ____-____-______ Misc #: ____-____-______
Name: _______________ , ______________ ____________
(Last) (First) (Middle)
Address: _________________________________________________
(Street)
________________ ________ ________ __________
(City) (State) (Zip code) (County)
Relationship
To client: ________________________
Home phone #: ____-____-______ Cell #: ____-____-______
Work #: ____-____-______ Misc #: ____-____-______ |