Date of birth: Student’s full name(s): Any allergies, medications or special conditions: Home address: Closest major intersection: Poison Control: 1-800-567-8911 Police Department (non emergency) (250) 248-6111 Fire Department: (non emergency) (250) 248-3242 (250) 752-6232 Qualicum Other Emergency #: Parksville Family Doctor phone: Family Doctor: Address: Directions: Dentist phone: Dentist: Hospital phone: Preferred hospital: Address: Directions: Insurance provider phone: Insurance provider: Group ID: Policy ID: Insured name and ID: full name: Host Mom’s Preferred phone: Preferred phone: Other phone: Other phone: Host full name: Dad’s Emergency contact 1: Emergency contact 2: Phone: Phone: Relation:
Student’s full name(s): Date of birth: Any allergies, medications or special conditions: Home address: Closest major intersection: Police Department (non emergency) (250) 248-6111 Poison Control: 1-800-567-8911 Fire Department: (non emergency) (250) 248-3242 Parksville (250) 752-6232 Qualicum Other Emergency #: Family Doctor: Family Doctor phone: Address: Directions: Dentist: Dentist phone: Preferred hospital: Hospital phone: Address: Directions: Insurance provider: Insurance provider phone: Insured name and ID: Group ID: Policy ID: Host Mom’s full name: Preferred phone: Other phone: Host Dad’s full name: Preferred phone: Other phone: Emergency contact 1: Phone: Relation: Emergency contact 2: Phone:
QISP-Emergency-Sheet.docx