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Emergency Preparedness 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 ___________________________________.

Emergency Preparedness Plan

Mobile emergency kit supplies are kept _____________________________________ (location within the home). I will check supplies and practice monthly drills and record on an evacuation/fire drill form. 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.
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 __________________.
“Shelter-in-place” supplies are kept ____________________________________ (location in the home).
I will check supplies every month and document on a shelter-in-place drill form.
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

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