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Please Print This Page and fill it in, using ink.
Then attach it to the back of your child's car seat in case of an emergency.

Child's Name:

Birth Date:__/__/____
Address: City: State:

Medical Conditions/ Allergies:

 

 Hair Color and Eye Color:

Scars/Birthmarks:
Mother/Guardian: Home phone:

Alt phone:

 

Father/Guardian

 

 Home phone: Alt phone:

Emergency Contact (other than parent/guardian)

 

 Home phone: Alt phone:

Child's Doctor:

 

 Phone Pager