Emergency Response Plan Template

Provider’s name: __________________________ Child’s name: ______________________________

Provider’s address: __________________________________________________________________

Provider’s Phone number: ___________________

Evacuation Plans

If there is an emergency that requires an evacuation of this home, one of the following plans will be used:

  • If the emergency requires that the children and I evacuate from my home, I will take the children to _____________________________ (address nearby) at _____________ (phone number) or _____________________________ (address further away) at _____________ (phone number).

  • If a medical examination or treatment is needed, I will take the children to _____________________________________________ (facility and address) unless emergency personnel designate another location.

  • If an emergency requires a larger area evacuation, I will take the children to a mass shelter designated by emergency personnel.

  • If it is too far to walk, I will transport the children by ___________________________________.

  • I will practice evacuation drills every month and document on evacuation/fire drill form (pdf-icon-small English, pdf-icon-small Spanish).

Emergency Preparedness Plan

  • If there is an emergency where "Shelter-in-Place" is required, all the children and I will go to______________________________________ (room/place) in the home and remain there until rescued or notified that conditions are safe. I will sound the emergency alarm by____________________________ .
  • Mobile emergency kit supplies are kept______________________________ (location within the home). I will check supplies and practice monthly drills and record on a Shelter in Place Drill form (pdf-icon-small English, pdf-icon-small Spanish). I will maintain supplies that are appropriate for the ages of children in my care.
  • I will stay with the children at all times during the emergency. I will check and record time and attendance before evacuation and whenever children are moved. I will bring any necessary medications, supplies, and essential emergency records/documents for the children.
  • Shelter-in-place supplies are kept______________________________ (location in the home).
  • In any emergency, I will contact family/emergency contacts to make plans to reunite the parent and child.
  • I will train all adults who help care for the children about the emergency plans and procedures.
  • I will post emergency evacuation and shelter-in-place routes and procedures in my home.
  • I will review my emergency response plan every six months.

Communication/Notification Plan

  • I will talk to parents about my emergency plans or any changes in the emergency plan.
  • I will update emergency contact information every six months with parents/guardian.
  • I will notify parents by calling work, home, and/or cell phones, BlackBerries, pagers, e-mail or fax numbers, as applicable.
  • The plan will include current phone numbers and names of individuals at the parent’s work site who can locate the parents if they are not at their work phones.
  • If parents cannot be reached, I will contact the friends, relatives and neighbors who are authorized to pick up a child in an emergency.
  • I will try to identify an out of town contact person that can be reached by phone or email: _________________________________ (name), ______________________ (phone), ___________________________________________ (email address).
  • In the event that I receive different instructions from emergency personnel, I will make every attempt to contact parents/guardians/emergency contacts with the alternate plans.

_________________________          ___________________________       _______________
Provider’s Signature                         Parent’s Signature                            Date

Provider is responsible for keeping emergency response plan information current with parents or guardians.

Provider’s Signature: _________________________________________

Six-Month Review________________ Parent’s Initials_______ One-year Review ________________ Parent’s Initials_______
                          Date                                                                                   Date


Download this plan in pdf-icon-small  English or pdf-icon-small Spanish.

Emergency Preparedness and Supplies Guide


Go back to: Apply for a Family Child Care Permit


Contact Fairfax County: Phone, Email or Twitter | Main Address: 12000 Government Center Parkway, Fairfax, VA 22035
Technical Questions: Web Administrator

ADA Accessibility | Website Accessibility
Awards | FOIA | Mobile | Using this Site | Web Disclaimer & Privacy Policy | Get Adobe Reader
Official site of the County of Fairfax, Virginia, © Copyright 2015

Website Feedback Website Feedback    Globe with various flags representing Web site language translations   Language Translations

Return to Graphic Version