EMERGENCY FAMILY INFORMATION

Head of Household _______________________________              Unit # ___________________________    Ext ______________________

FAMILY COMPOSITION:
NAME	DOB	SEX	RELATIONSHIP	

				

				

				

				

In Case of Emergency Contact:

	1.	Name __________________________________				2.	Name _________________________________
		Address ________________________________					Address _______________________________
			  ________________________________					               _______________________________
		Phone _________________________________					Phone _________________________________
		Relationship ____________________________					Relationship ____________________________

I,  _______________________________________________, give permission for the above person/s to take care of my children in case of an emergency.

___________________________									---------------------------------------------------------
Head of Household											Date Completed

___________________________									---------------------------------------------------------
Witness 												Date Completed

Emergency Medical Information: ______________________________________________________________________________________

Maintain on a 3 X 5 card at the security desk.