BLOOMING HORIZONS LLC

EMERGENCY MEDICAL INFORMATION AND EMERGENCY CONTACT FORM

INFORMATION CURRENT AS OF Date: __ /__ /____
APPLICANT INFORMATION

Name: DOB( Month/Year)

Current address:
Primary Caregiver:

Primary Caregiver Mobile:

Nickname:

Medical/Physical limitation:

Communication level:

Physical Description:

Male ____ Female _____ Height______ Weight_______

Eyecolor _______ Hair Color_________

Special Medications: ________________________________________________________________________________________________

Food or drug allergies:______________________________________________________________________________________________

Other relevant conditions (check all that apply):

No sense of danger Prone to seizures Blind Deaf Intellectual Disability Communication Disorder

What may be presented in an emergency (e.g. medications, reinforces, etc.): -

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

In case of emergency DO NOT:

Recommended Interventions (Caregiver):

Recommended Interventions (Clinical Supervisor):

Emergency Contacts- In case of Emergency call 911

 Name Relationship Mobile no. 1 Mobile no. 2

Patient’s pediatrician:

Pediatrician’s Phone Number: