Foster Family ______Plan Date______
Assuring Love Child Placement Agency
Foster Family
Emergency/Disaster Plan
Home Address: ______
Directions to Home:
Home Phone: ______Alt. Phone ______
Foster Parent I: ______Work Ph.: ______Cell Ph:______
Foster Parent II: ______Work Ph.: ______Cell Ph:______
· In the case of an emergency/natural disaster (i.e. tornado, flood, fire, terrorism, etc...) what are your plans?
_____ Evacuate
_____ Remain in the Home
· In the event it is necessary to evacuate your home, give two places to meet:
o A place right outside the home in case of a sudden emergency
o A place outside the neighborhood in case return home is not possible.
· In the event it is necessary to evacuate the area, where will the family go?
Name of Residence or Facility: ______
Relationship: _____ Relative _____ Friend _____ Other: ______
Address: ______
Phone:______Cell Phone (if applicable) ______
Name of Residence or Facility: ______
Relationship: _____ Relative _____ Friend _____ Other: ______
Address: ______
Phone:______Cell Phone (if applicable) ______
· Describe transportation if evacuation is necessary:
· What will happen to the child(ren) if he/she is in school or the foster parent(s) is away from the child.
_____ Child will remain until a parent or designated adult can pick them up
_____ Child will go home on their own.
_____ Other:
· Are there any children in the home who take prescribed medication or other special medical needs?
Name:______
Medicine(s)/Special Needs: ______
Name:______
Medicine(s)/Special Needs: ______
Name:______
Medicine(s)/Special Needs: ______
· Is there anyone in the home that would require other special attention during an evacuation?
Name:______
Condition: ______
Name:______
Condition: ______
· Contact Information for the doctor of each of the children:
Name: ______
Address: ______
Phone: ______
Name: ______
Address: ______
Phone: ______
· School Information for each of the children:
Name: ______
Address: ______
Phone: ______
Name: ______
Address: ______
Phone: ______
· Contact Information for the Caseworker of each of the children:
Child______
Caseworker: ______Phone: ______
CW Supervisor: ______Phone: ______
Child______
Caseworker: ______Phone: ______
CW Supervisor: ______Phone: ______
Child______
Caseworker: ______Phone: ______
CW Supervisor: ______Phone: ______
Child______
Caseworker: ______Phone: ______
CW Supervisor: ______Phone: ______
Attach a diagram of the home with the following:
Ø Escape routes indicated
Ø At least two ways out of each room
Ø Safe spots in the home
Ø Written guidelines of what to do in an evacuation
In addition, each home must show Case Manger and maintain at a minimum:
¾ A First Aid Kit
¾ An Operable Flashlight with an Adequate Battery Supply
¾ A Battery Operated Radio
¾ A Container for Transportation of Medications
¾ Other:
Foster Parent I: ______Date: ______
Foster Parent II: ______Date: ______
Case Manager ______Date: ______