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Critical Medical Information Form

Click here for a printable version of this form in Word format.

Click here for a printable version of this form in PDF format.

 The Critical Medical Form can be freely downloaded for families to print out and used for any person with special needs. This form will help Emergency Responders assist in the event that a caregiver is unable to respond and provide information about the specail needs person.  USES:* For anyone with any special need* Parents of young or nonverbal children*  Field trip information for staff. * Paid Caregiver who drives* School Bus driver* During vacation* Group home staff This is a 2 sided document that has 3 forms on it. It is recommend to use all 3 forms for each person. Put one in a clip-on badge holder and attach to a car seat or near where the special needs person sits, put one in a glovebox of the car and one over the visor.  IF the driver is unable to respond,  basic information will be available to any first responder.  It is advisable to add a recent photo to the form as well.  




This information sheet was developed and is provided by SPEAK Unlimited Inc. We retain all rights to it.  PERMISSION: You are permitted and encouraged to reproduce and distribute this material in any format provided that you do NOT alter the wording in any way, you do not charge a fee beyond the cost of reproduction, and you leave this notice on all reproductions. Additional information on police training and family supports can be acquired by e-mailing Susan Rzucidlo at srz@dol.net                       

SPEAK Ulimited Inc P.O. Box 98, Landenberg PA 19350   (610) 274-2364      (610) 274-2205 FAX      info@papremisealert.com