FORM FOR BABYSITTERS

FOR LIFE THREATENING EMERGENCIES: CALL 911

FAMILY NAME: _____________________________________________________

CHILDREN'S NAMES:

______________________________________________AGE:_______________

FAMILY ADDRESS:_________________________________________________

NEAREST CROSS STREETS:_________________________________________

NUMBER TO CONTACT PARENTS:_____________________________________

DOCTOR'S NAME:__________________________PHONE:__________________

HOSPITAL:________________________________PHONE:__________________

POISION CONTROL CENTER 1-800-222-1222 in Minnesota ___________________

NEIGHBORS NAME TO CONTACT FOR HELP:___________________________________

NEIGHBOR PHONE NUMBER:_________________________________________

ADDITIONAL INSTRUCTIONS:_________________________________________

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