Client Emergency Preparedness Document

Location *

Client First Name

Client Last Name

Date of Birth *

Primary Caregiver First Name

Primary Caregiver Last Name

Primary Caregiver Phone

Relationship to Client (Primary Caregiver) *

Emergency Contact First Name

Emergency Contact Last Name

Relationship to Client (Emergency Contact) *

Emergency Contact Phone Number *

Evacuation & Shelter Plan *

Evacuation Address — Street (if transported)

Evacuation Address — City

Evacuation Address — State/Region/Province

Evacuation Address — Postal / Zip Code

Emergency Supplies (comma-separated: Medications, Medical equipment, Identification, Emergency contacts list, Mobility Device, Personal hygiene items, Other) *

Alternate Care Arrangement — First Name

Alternate Care Arrangement — Last Name

Alternate Care — Relationship to Client