Family Interview Form
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6Family Interview Form
Family Information and Emergency Numbers
Today’s date: ____________________________________________________________
Family name: ____________________________________________________________
Home phone number: _____________________________________________________
Address: ________________________________________________________________
E-mail address: ___________________________________________________________
Nearest cross-street: ______________________________________________________
Phone number where parent can be reached during babysitting job: ______________
Medical
Child’s name
Age
Weight
Medicines
Allergies
problems
Mobile phone number: ____________________________________________________
Neighbor’s name and phone number: ________________________________________
Name and phone number of an adult who can make decisions if the parent cannot
be reached: _____________________________________________________________
Local emergency phone number: ___________________________________________
Doctor’s name: ___________________________________________________________
Doctor’s phone number: ___________________________________________________
Name of preferred hospital to be used in an emergency: _________________________
National Poison Control Center (PCC) hotline: (800) 222-1222
FA M I LY I N T E R V I E W F O R M
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Parent category: Business