babysitter emergency contact form

Childcare Provider Emergency Authorization and Contact Information

Instructions for Use

• Complete all sections of this document in blue or black ink prior to the start of the childcare session.
• Print a physical copy to keep in a visible location (e.g., on the refrigerator) and provide a digital copy to the childcare provider.
• Review and update the medical and contact details periodically to ensure all information remains accurate and current.

Parties and Identification

Child(ren) Information: Name: [Full Legal Name] | Date of Birth: [Date] Name: [Full Legal Name] | Date of Birth: [Date] Name: [Full Legal Name] | Date of Birth: [Date]

Primary Parents/Guardians: Name: [Full Legal Name] | Phone: [Phone Number] Name: [Full Legal Name] | Phone: [Phone Number]

Operative Clauses

1. Emergency Contact Protocol: In the event of an emergency, the childcare provider shall attempt to contact the Primary Parents/Guardians first. If they are unreachable, the provider is authorized to contact:

   • Name: [Full Legal Name] | Phone: [Phone Number] | Relationship: [__________]
   • Name: [Full Legal Name] | Phone: [Phone Number] | Relationship: [__________]

2. Medical Authorization: The childcare provider is authorized to seek emergency medical treatment for the child(ren) listed above if a parent or guardian cannot be reached. This includes authorization for paramedics, hospital staff, and physicians to perform necessary diagnostic tests or emergency procedures.

3. Medical History and Allergies:

   • Known Allergies: [__________]
   • Current Medications: [__________]
   • Medical Conditions: [__________]
   • Primary Physician: [Full Name] | Phone: [Phone Number]

4. Insurance Information:

   • Insurance Provider: [Company Name]
   • Policy Number: [__________]
   • Group Number: [__________]

5. Household Protocols:

   • Home Address: [Street Address, City, State, Zip]
   • Security System Code (if applicable): [__________]
   • Fire Escape/Meeting Point: [__________]
   • Household Rules/Restrictions: [ ] No visitors [ ] No screen time [ ] Other: [__________]

Signature and Acknowledgment

By signing below, I confirm that the information provided is accurate and grant the childcare provider the authority to act in the interest of the child's safety as outlined above.

Parent/Guardian Signature: __________ Printed Name: [Full Legal Name] Title: Parent/Legal Guardian Date: [Date]

DISCLAIMER: This document is a general framework and does not constitute legal advice. Laws regarding medical consent and childcare vary by jurisdiction. Please consult with qualified legal counsel to ensure compliance with your local laws and specific family requirements.