Emergency Contact Form for Foster Caregivers and EFC Youth

Emergency Contact Form Information

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Date Completed(Required)

Region of Worker(Required)

Assigned Worker(Required)

Check Type of Home(Required)

DCFS-Certified Foster/Adoptive Parent(s)

Therapeutic Foster Home (Private Agency)

Non-certified Foster Caregiver (Relative/Fictive Kin/Trial Placements)

ICPC Placement (Child placed out of state or by another state in LA)

EFC Participant

Select One Type Only

Youth/Caregiver Information

Name of Youth/Caregiver (as listed in TIPS)(Required)

First Last

Name of Youth/Caregiver (as listed in TIPS)(Required)

First Last

TIPS Provider Number OR TIPS Client Number (EFC and Trial Placements)

Preferred Phone Number(Required)

Can the preferred phone number receive text messages?(Required)

If preferred phone number cannot receive text messages, you may add an alternate phone number to receive text messages.

Cell Number to receive Text Alerts

Other Phone Number

E-mail Address

Current Address(Required)

Street Address City State ZIP Code

Emergency Contact Information

List two (2) persons who can be reached to locate/contact you in case of an accident/emergency and/or individuals you stay with in the event of an emergency.

Emergency Contact #1

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Other Phone

Email Address

Phone (preferred)(Required)

Cell Phone

Emergency Contact #2

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone (preferred)(Required)

Cell Phone

Other Phone

Email Address

I am

Child Welfare

Family Services

Child Support

Programs

Become a Foster Caregiver

Adopt a Child or Teen

Foster Care

Adoption

Programs

Mandated Reporters

Elected Officials

Medical Professionals

Providers

Teachers & School Personnel

I am

Child Welfare

Family Services

Child Support

Programs

Become a Foster Caregiver

Adopt a Child or Teen

Foster Care

Adoption

Programs

Mandated Reporters

Elected Officials

Medical Professionals

Providers

Teachers & School Personnel

Emergency Contact Form for Foster Caregivers and EFC Youth

Emergency Contact Form Information

Youth/Caregiver Information

Emergency Contact Information

Emergency Contact #1

Emergency Contact #2