Emergency Preparation Forms

Program Tool

WWW.VIRTUALLABSCHOOL.ORG

ACTIVITY ID: 22476

Name

Certifier

Date

Talk with your administrator. Complete this form with information from your program.

School-Age Program Information
Name of Program
Street Addresss
City
State
Zip Code
Telephone Number
Alternate Facility 1 (Program may operate in this facility if the main facility is not accessible)
Name of Facility
Street Addresss/Building Number
City
State
Zip Code
Telephone Number
Directions to Facility
Alternate Facility 2 (Program may operate in this facility if the alternate facility is not accessible)
Name of Facility
Street Addresss/Building Number
City
State
Zip Code
Telephone Number
Directions to Facility
Primary Point of Contact (Administrator) for my Facility
Name
Telephone Number
Alternate Telephone Number
Email Address
Emergency Contacts
Life Threatening Emergency	911
Non-Emergency Police
Non-Emergency Fire
Insurance Provider
Emergency Essential Personnel
Staff Name
Staff Name
Staff Name
Staff Name
Evacuation Plan
Evacuation Manager and Alternate
Person responsible for issuing all-clear
Assembly site manager and alternate
Assembly site location
Person able to handle medical emergencies
Location of evacuation exits
Location Nearby Assembly Site
Location of Distant Assembly Site
Location of More Distant Assembly Site
Shelter-In-Place Plan
Person responsible for issuing all-clear
Person able to handle medical emergencies
Storm shelter location
Person responsible for maintaining and refreshing emergency supplies
Location where personal supplies are stored (if staff must remain in building for extended period of time)
Location where children's supplies are stored for extended shelter-in-place events
Materials included in shelter-in-place kit
Evacuation Plan
Evacuation Manager and Alternate
Person responsible for issuing all-clear
Assembly site manager and alternate
Assembly site location
Person able to handle medical emergencies
Location of evacuation exits
Location of Nearby Assembly Site
Location of Distant Assembly Site
Location of More Distant Assembly Site
Lock-Down Plan
Person responsible for issuing all-clear
Person able to handle medical emergencies
Lock-down shelter locations in classroom
Lock-down shelter locations in common areas (playground, etc.)
General Emergency Plan
Location of First Aid kit in classroom
Communications
How will emergency plans be communicated to me?
How will emergency plans be communicated to families?
How can I check in with my administrator following an emergency?

Adapted from Child Care Aware USA (2006) and Sample Emergency Plan available from the federal Emergency Management Agendy Ready website.