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Babysitter Information Sheet
Where I will be: ______________________________________________________________________________
Phone number to reach me: ____________________________________________________________________
IF YOU CANNOT REACH ME
Contact name: _________________________________ Contact phone number: ________________________
Contact name: _________________________________ Contact phone number: ________________________
In an emergency call 911
HOME INFORMATION
Family Name: ________________________________________________________________________________
Phone: ______________________________________________________________________________________
Address: _____________________________________________________________________________________
ABOUT THE CHILD(REN)
Name: ____________________________________
Date of Birth: ______________________________
Age: ______________________________________
Other Information (allergies, medications, etc.):
___________________________________________
___________________________________________
___________________________________________
Name: ____________________________________
Date of Birth: ______________________________
Age: ______________________________________
Other Information (allergies, medications, etc.):
___________________________________________
___________________________________________
___________________________________________
PEDIATRICIAN
Name: ____________________________________
Phone: ____________________________________
Address: __________________________________
CLOSEST HOSPITAL
Name: ____________________________________
Phone: ____________________________________
Address: __________________________________
INSURANCE INFORMATION
Provider: _________________________________
Name of Insured: ___________________________
Group number: ____________________________
Policy number: ____________________________