Emergency Child ID Record
A private record of important information to be given to authorities should the need arise.


Child’s Name:

Assemblyman Brian Kolb
Document provided
courtesy of
Assemblyman
Brian Kolb

Click here for a printable version


Attach
most
recent
photo
here.
Personal Information


Name (Last)


(First)


(Middle)


(Nickname)


Date of Birth
Social Security Number



Mother’s Name

(       )
Phone
SS#




Father’s Name

(       )
Phone
SS#




Street


City
Zip
State

Fingerprints  Most Police Departments will fingerprint your child for free.


Medical Information

(          )

Doctor’s Name
Phone


(          )

Birth Hospital
Phone


M     F
Sex
Blood Type



Race
Complexion



Eye Color
Hair Color



Height
Weight



Shoe Size
Clothing Size


YES     NO
YES     NO
Glasses?
Braces?



Chronic Illnesses


Medications


Allergies

DNA Sample
Dental Records
Have your child’s dentist complete this section.



Dentist’s Name

(          )
Phone

Dental Records


Child’s Favorite Things



Places








Foods








Pastimes








Other Identifying Activities, Mannerisms, etc.








It is my sincere hope that this document is never needed, but that completing it may offer some peace of mind to parents and guardians.

If you would like more copies, please do not hesitate to contact my offices:

607 West Washington Street • Geneva, NY 14456 • (315) 781-2030 or
446 Legislative Office Building • Albany, NY 12248 • (518) 455-5772
E-mail: kolbb@assembly.state.ny.us

— Assemblyman Brian Kolb


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