babysitter emergency information sheet template

Child Care Emergency Protocols and Contact Authorization

Instructions for Use

• Print this document and complete all fields in permanent ink; keep a copy in a visible location (e.g., refrigerator) and provide a digital copy to the caregiver.
• Review all medical, allergy, and authorization sections with your caregiver in person to ensure they understand the specific protocols for your household.
• Update this form immediately if there are changes to contact information, medical conditions, or authorized pickup persons.

Parties & Definitions

Parent(s)/Guardian(s): [] and [] Caregiver: [] Child(ren): [], [], [] Primary Residence Address: [__________]

Operative Clauses

1. Emergency Contact Hierarchy. In the event of an emergency, the Caregiver shall attempt to contact the Parent(s)/Guardian(s) in the order listed below. If unreachable, the Caregiver is authorized to contact the designated local emergency contacts:

   • Primary Parent: [] | Phone: []
   • Secondary Parent: [] | Phone: []
   • Emergency Contact 1: [] | Phone: []
   • Emergency Contact 2: [] | Phone: []

2. Medical Authorization. The Caregiver is authorized to seek emergency medical treatment for the Child(ren) if the Parent(s)/Guardian(s) cannot be reached.

   • Pediatrician: [] | Phone: []
   • Preferred Hospital: [] | Phone: []
   • Insurance Provider: [] | Policy Number: []

3. Allergies and Dietary Restrictions. The Caregiver acknowledges the following medical conditions and food allergies:

   • Known Allergies: [__________]
   • Required Medication/EpiPen Location: [__________]
   • Dietary Restrictions: [__________]

4. Authorized Pickup Persons. Only the following individuals are authorized to remove the Child(ren) from the premises:

   • [__________]
   • [__________]
   • [__________]

5. Household Protocols.

   • Security System Code: [__________]
   • Wi-Fi Network: [] | Password: []
   • Bedtime/Nap Schedule: [__________]
   • Screen Time/Media Rules: [__________]

Signature & Acknowledgment

By signing below, the parties acknowledge that the information provided is accurate and that the Caregiver is authorized to act in accordance with the protocols established herein.

Parent/Guardian Signature: __________ Printed Name: [] Date: []

Caregiver Signature: __________ Printed Name: [] Date: []

Legal Disclaimer: This document is a general framework and does not constitute legal advice. Requirements for medical authorization and child care liability vary by jurisdiction. Please consult with qualified legal counsel to ensure compliance with local laws and regulations.