EMERGENCY CARD

Emergency Card For:

Child’s Full Name: Date:
Zip
Child’s Home Address: City: Jersey City State: NJ :
Mother’s Name: Father’s Name:

Mother’s Contact Information Father’s Contact Information

Employer: Employer:
Work Phone: Work Phone:
Cell Phone: Cell Phone:
Home Phone: Home Phone:
E-Mail: E-Mail:

If parents are not available, please contact:

Name/Relation: Phone:
Name/Relation: Phone:

Name/Relation: Phone:

*Medical Information:
Allergies (food, medicine, other):
Special Instructions:

Emergency Card For: Date:

Description: Right Hand Left Hand Recent Photo:

Date of Birth:
Thumbs:
Gender:
Ethnic Origin:
Index:
Height:
Weight:
Middle:
Eye Color:
Hair Color:
Ring:
Physical Characteristics (Birthmark/Mole):

Little:

Blood Type: