Louisiana.gov DCFS

Emergency Contact Form for Foster Caregivers and EFC Youth 2025

Date Completed

Assigned Home Development Worker

Region Where you LIve

Region of Worker

Select Type of Home

If ICPC, which state is sending child for placement?

Child/Young Adult and Caregiver Information

Name of Caregiver/EFC Young Adult

Name of Child in Foster Care

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

Preferred Phone Number

Can the preferred number receive text messages?

Cell Number to receive Text Alerts

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

This is optional

E-mail Address

This is optional

Current 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

Street Address

City

State

Zip Code

Phone (preferred)

Cell Phone

Email Address

Emergency Contact #2 Name

Street Address

City

State

Zip Code

Phone (preferred)

Cell Phone

Email Address