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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