The following form gives emergency providers the information they need to properly care for your child. Ask your child's primary care provider (PCP) to fill out and sign this form. Give a copy of this form to anyone who may take care of your child in an emergency.

It is very important to update the form after any of the following events:

  • Important changes in your child's condition or diagnosis

  • Any major surgical procedures

  • Major changes in medications or dosages

  • Changes in health care providers

After updating the form, remember to give new copies to emergency medical services (EMS), your child's providers, and caregivers.

Suggestions on where to keep copies of this form:

  • Health Care Provider's Office: On file with each of the child's health care providers, including specialists.

  • Home: At the child's home in a place where it can be easily found, such as on the refrigerator.

  • Car: In the glove compartment of each parent/guardian's car.

  • Work: At each parent's workplace.

  • Purse/Wallet: In each parent's purse or wallet.

  • School: On file with the child's school, such as in the school nurse's office.

  • Child's Belongings: With the child's belongings when traveling.

  • Emergency Contact Person: At the home of the emergency contact person listed on the form.

  • Local EMS: Give to local ambulance services and hospital emergency departments. Keep more copies on-hand to give to emergency service providers during an emergency situation.

Tip: You can also find a copy of the Emergency Information Form in Chapter 1.


This information is provided by the Division of Perinatal, Early Childhood, and Special Health Needs within the Department of Public Health.