Use your browser's print button to print this page.  Complete the form, make copies for yourself and other caregivers who take your child out.

 

Staple a current photo of your child to the form.  Keep the form and photo updated at all times.  Keep copies in your purse, wallet, diaper bag,etc.

 

In the event that your child gets separated from you, give this form and photo to a law enforcement officer immediately.

 

 

CHILD'S NAME__________________________________________________

 

NICKNAME/NAME CHILD ANSWERS TO______________________________

 

AGE___________________    HAIR COLOR___________________________

 

EYE COLOR_____________________  HEIGHT__________ WEIGHT_______

 

DISTINGUISHING MARKS/FEATURES________________________________

 

_______________________________________________________________

 

_______________________________________________________________

 

MEDICAL ALERTS________________________________________________

 

MOTHER'S CONTACT PHONE_______________________________________

 

FATHER'S CONTACT PHONE________________________________________

 

OTHER EMERGENCY CONTACT PHONE_______________________________