Emergency Reference Sheet

Household Emergency Information

Contact information for household members. Please complete this form and keep it up to
date. Make copies to share with each family member.

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Family Member 1

Family Member 2

Name:__________________________________________________

Name:__________________________________________________

Date of Birth:____________________________________________

Date of Birth:____________________________________________

Social Security Number:___________________________________

Social Security Number:___________________________________

Phone Number (Work):____________________________________

Phone Number (Work):____________________________________

(Evening):__________________________________

(Evening):__________________________________

(Mobile):___________________________________

(Mobile):___________________________________

Personal Email:___________________________________________

Personal Email:___________________________________________

Blood Type:______________________________________________

Blood Type:______________________________________________

Prescriptions:____________________________________________

Prescriptions:____________________________________________

Business, School or Other Evacuation Information:

Business, School or Other Evacuation Information:

Location:________________________________________________

Location:________________________________________________

Address:________________________________________________

Address:________________________________________________

Phone Numbers:__________________________________________

Phone Numbers:__________________________________________

Family Member 3

Family Member 4

Name:__________________________________________________

Name:__________________________________________________

Date of Birth:____________________________________________

Date of Birth:____________________________________________

Social Security Number:___________________________________

Social Security Number:___________________________________

Phone Number (Work):____________________________________

Phone Number (Work):____________________________________

(Evening):__________________________________

(Evening):__________________________________

(Mobile):___________________________________

(Mobile):___________________________________

Personal Email:___________________________________________

Personal Email:___________________________________________

Blood Type:______________________________________________

Blood Type:______________________________________________

Prescriptions:____________________________________________

Prescriptions:____________________________________________

Business, School or Other Evacuation Information:

Business, School or Other Evacuation Information:

Location:________________________________________________

Location:________________________________________________

Address:________________________________________________

Address:________________________________________________

Phone Numbers:__________________________________________

Phone Numbers:__________________________________________

Health and Home/Rental

Insurance Information

Name

Telephone#

Policy#

Health Insurance:
Family Physician (1):
Family Physician (2):
Home Owners/Rental
Insurance:
Other (1):
Other (2):

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Primary Emergency Contacts

Out-Of-State
Name:__________________________________________________
Address:________________________________________________
City:____________________________________________________
State:______________________________Zip:__________________
Telephone (Day):_________________________________________

(Evening):______________________________________

(Mobile):_______________________________________

Email:___________________________________________________

Local Emergency Officials

In a life threatening emergency, dial 911 or the local emergency

medical service officials:
Nearest Police Department:___________________________
Address:________________________________________________
Telephone:_______________________________________________
Nearest Fire Department:_____________________________
Address:________________________________________________
Telephone:_______________________________________________
Nearest Hospital:_____________________________________

Nearest Relative

Address:________________________________________________

Name:__________________________________________________

Telephone:_______________________________________________

Relationship:_____________________________________________
Address:________________________________________________
City:____________________________________________________

Family Reunion Locations

Location 1. Right outside your home_______________________

State:______________________________Zip:__________________

________________________________________________________

Telephone (Day):_________________________________________

_________________________________________________________

(Evening):______________________________________

_________________________________________________________

(Mobile):_______________________________________

Location 2. Away from the neighborhood, in case you cannot

Email:___________________________________________________

return home:

Nearest Neighbor

Meeting Place:___________________________________________

Name:__________________________________________________

________________________________________________________

Address:________________________________________________

Address:________________________________________________

City:____________________________________________________

Telephone Number:_______________________________________

State:______________________________Zip:__________________

Driving/Walking route(s):__________________________________

Telephone (Day):_________________________________________

________________________________________________________

(Evening):______________________________________

________________________________________________________

(Mobile):_______________________________________

________________________________________________________

Email:___________________________________________________

________________________________________________________

In an Emergency Call 9-1-1

Call this number for emergency response only if:
You are in danger
You witness a crime in progress
Someone has serious injuries or
medical problems
Situation needs urgent attention
DO NOT CALL 9-1-1-for non-emergencies
or to report a power outage

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