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EVACUATION SITE AGREEMENT FORM
I hereby give permission for ____________________________________________ child care provider to use the below listed site as an emergency evacuation site for child care staff and children during a drill or actual emergency event.
This agreement will remain in effect until Month, Date, Year: ________________________________________________________ The agreement may be terminated before this date by either party, but only with written notification.
Evacuation Site Name: _______________________________________________________________________________________ Evacuation Site Address: _____________________________________________________________________________________ Evacuation Site Contact Person: _______________________________________________________________________________ Evacuation Site Contact Number: ______________________________________________________________________________ Alternate Contact Number: ___________________________________________________________________________________
Is site accessible at all times the child care program is open? ________ Yes ________ No
Include any information needed to access and enter the site: _______________________________________________________ __________________________________________________________________________________________________________
Number of Children and Staff Capacity: __________
Check off items that the evacuation site will provide in an emergency: o Water
o Food
o Transportation
o Telephone
o People to assist
o Other _____________________________________________________________________________________________
Please include any special considerations (storage room, restrooms, wheel chair accessible, etc.): __________________________________________________________________________________________________________
Evacuation Site Representative
Printed Name: _____________________________________________________________________________________________ Signature: ___________________________________________________________________ Date: _______________________
Child Care Program Representative
Printed Name: _____________________________________________________________________________________________ Signature: ___________________________________________________________________ Date: _______________________
Save the Children Federation, Inc. Child Care Emergency Preparedness Training Manual (2010) 20