This information is approved and/or reviewed by U-M Health System providers but it is not a tool for self-diagnosis or a substitute for medical treatment. You should speak to your physician or make an appointment to be seen if you have questions or concerns about this information or your medical condition. Exención de responsabilidad en Español | Complete disclaimer
Home Address:____________________Nearest cross street: __________________
Home Phone Number: _________________ Parents' Cellphone
Number:_______________
Expected return time: ______________________________________
Emergency Number (Police/Fire) _____________________________
Doctor's Name_______________________________________________
Doctor's Phone Number ______________________________________
Poison Control Center Hotline 800-222-1222
Neighbor's Name_____________________________________________
Neighbor's Phone ___________________________________________
Child's Name: ________________________ Age:_________________
Allergies or Special Instructions: _____________________________
Child's Name: ________________________ Age:_________________
Allergies or Special Instructions: _____________________________
Child's Name: ________________________ Age:_________________
Allergies or Special Instructions: ______________________________
Areas off limits____________________________________________
Message to give if someone calls: ____________________________
____________________________________________________________
What to do about visitors: ____________________________________
____________________________________________________________
Guidelines for TV/computer use: ________________________________
____________________________________________________________
Location of fire extinguisher: _____________________________________
Location of flashlights and first aid supplies__________________________
Evacuation route if the smoke detector goes off: _____________________
____________________________________________________________
Other (feeding, bathing, and sleeping arrangements): ____________________________________________________________
____________________________________________________________
