Caregiver Emergency Contact & Support Network

Emergencies can happen without warning. This simple tool helps caregivers organize key contacts, backup support, healthcare information, and one immediate preparedness action step.

Complete the sections below, then print or save your completed plan.

Note: This tool is for personal preparedness only. Please do not submit sensitive medical information through a public website form.

Caregiver Emergency Contact & Support Network Builder

Use this tool to organize emergency contacts, backup caregivers, healthcare information, and your next preparedness step.

1. Person Receiving Care

Name: Date of Birth: Primary Medical Conditions: Known Allergies:

2. Emergency Contacts

Primary Contact Name: Relationship: Phone: Email: Secondary Contact Name: Relationship: Phone: Email:

3. Backup Caregiver Support

Backup Caregiver #1: Phone: How can they help? Backup Caregiver #2: Phone: How can they help?

4. Healthcare Contacts

Primary Doctor: Doctor Phone: Pharmacy Name: Pharmacy Phone:

5. Essential Documents Checklist

6. 72-Hour Care Plan

If I could not provide care for 72 hours, who would step in? Who would manage medications? Who would provide transportation? Who would make emergency decisions?

7. My One Preparedness Action Step

This week, I will:

Caregiver Emergency Contact & Support Network