babysitter emergency form

Child Care Emergency Authorization and Medical Consent Form

Instructions for Use

• Print this document and complete all fields in blue or black ink to ensure legibility for emergency responders.
• Keep a physical copy in a prominent location (e.g., refrigerator door) and provide a digital copy to the caregiver via secure messaging.
• Review and update the contact information and medical status every six months or whenever there is a significant change in the child's health.

Parties and Identification

Parent/Guardian(s): [] and [] Caregiver Name: [] Child(ren) Covered: [] (D.O.B: []) Home Address: []

Operative Terms

1. Emergency Medical Authorization: In the event of a medical emergency, the Caregiver is hereby authorized to consent to any X-ray, examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care deemed necessary by a licensed physician or surgeon.
2. Contact Protocol: The Caregiver shall make a reasonable attempt to contact the Parent/Guardian at [__________] (Phone) immediately upon discovering an emergency. If unreachable, the Caregiver shall contact the emergency contacts listed below in order of priority.
3. Emergency Contacts:
   • Name: [] | Relation: [] | Phone: [__________]
   • Name: [] | Relation: [] | Phone: [__________]
4. Medical History:
   • Allergies: [__________]
   • Current Medications: [__________]
   • Insurance Provider: [] | Policy Number: []
5. Physician Information:
   • Primary Pediatrician: [] | Phone: []
6. Authorization Duration: This authorization shall remain in effect from [] (Start Date) until [] (End Date), unless revoked in writing by the Parent/Guardian.
7. Liability Waiver: The Parent/Guardian agrees to indemnify and hold harmless the Caregiver from any and all claims, demands, or causes of action arising from the Caregiver’s good-faith efforts to secure emergency medical treatment for the child(ren).

Signature and Acknowledgment

By signing below, I affirm that I am the legal guardian of the child(ren) named above and that the information provided is accurate and current.

Signature: [] Printed Name: [] Title: [] Date: []

Legal Disclaimer: This document is a general framework and does not constitute formal legal advice. Laws regarding medical consent vary by jurisdiction. Please consult with qualified legal counsel to ensure this document meets the specific requirements of your state or locality.