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:___________________________________________________________

Work Phone:_________________________________________________________

Name of Employer:___________________________________________________________

Employer Address:_____________________________________________________________

Email Address:______________________________________________________

Parent’s Name:________________________________________________________________

Cell Phone:___________________________________________________________

Work Phone:_________________________________________________________

Name of Employer:___________________________________________________________

Employer Address:_____________________________________________________________

Email Address:______________________________________________________

Schools

Names of children’s schools:_______________________________________________________________________________________________________________________________________

School address:_______________________________________________________________________________________________________________________________________

School phone:________________________________________________________

School Website:______________________________________________________

Activities

Children’s activities schedule

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Addresses of activities:_____________________________________________________________________________________________________________________________________________________________________________________________________________

Websites of activities: __________________________________________________________________________________________________________________________________________________________________

Religious/Spiritual community:

Name of place of worship/reflection: ________________________________________________________________________

Dates and times:_________________________________________________________________

Address:_____________________________________________________________

Website:_____________________________________________________________

Discipline

It is important to us that our children be disciplined in a manner consistent with our values and child rearing practices. The following methods of discipline are totally unacceptable to us, and if our caretaker feels he or she requires these methods, we wish that person to decline to accept caring for our children:

Unacceptable discipline:

________________________________________________________________________

The following methods of discipline are those we most frequently use because we believe they are appropriate and effective:

Appropriate discipline:____________________________________________________________

________________________________________________________________________

Parenting Resources

Name of Closest Neighbors:___________________________________________________________

Address:_____________________________________________________________

Phone number:______________________________________________________________

Name of closest family:_______________________________________________________________

Address:_____________________________________________________________

Phone number:_____________________________________________________________

Storm/Fire Evacuation Plan

In the event of a storm, take the following precautions and go to:_____________________________________________________________________________________________________________________________________________

In the event of a fire, our plan is to evacuate and meet at: _______________________________________________________________________

Miscellaneous instructions _______________________________________________________________________________________________________________________________________________________________________________________________________________________