babysitter emergency information sheet template free

Childcare Emergency Protocol and Authorization Form

Instructions for Use

• Print this document and complete all fields in blue or black ink to ensure legibility.
• Keep one copy in a central, accessible location in your home (e.g., refrigerator or kitchen counter) and provide a duplicate to the designated caregiver.
• Review the information with your caregiver during every hand-off to ensure contact numbers and medical statuses are current.

Parties and Definitions

This Childcare Emergency Protocol (the "Protocol") is entered into by the Parent/Guardian, [], and the Caregiver, [], regarding the care of the following minor(s): [__________] (the "Children").

Operative Clauses

1. Emergency Contact Information

   • Primary Parent/Guardian: [] | Phone: []
   • Secondary Parent/Guardian: [] | Phone: []
   • Emergency Contact (Non-Parent): [] | Phone: []

2. Medical Provider Information

   • Primary Pediatrician: [] | Phone: []
   • Preferred Hospital: [] | Address: []
   • Preferred Pharmacy: [] | Phone: []

3. Medical History and Requirements

   • Known Allergies: [__________]
   • Current Medications: [__________]
   • Dietary Restrictions: [__________]
   • Special Medical Conditions: [__________]

4. Authorization for Emergency Medical Treatment The Parent/Guardian hereby authorizes the Caregiver to consent to any X-ray, anesthetic, medical, or surgical diagnosis or treatment and hospital care to be rendered to the Children under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

5. Caregiver Authority and Limitations

   • Caregiver is authorized to administer over-the-counter medication (e.g., acetaminophen, ibuprofen) per dosage instructions.
   • Caregiver is authorized to transport children in a personal vehicle.
   • Caregiver is NOT authorized to permit visitors in the home without prior written or verbal consent.

6. House Rules and Security

   • Alarm Code: [__________]
   • Wi-Fi Password: [__________]
   • Off-limit areas: [__________]
   • Bedtime/Curfew: [__________]

Signature and Acknowledgment

By signing below, the parties acknowledge that they have read, understood, and agreed to the terms of this Protocol.

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

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

Legal Disclaimer: This document is a general framework provided for informational purposes only and does not constitute legal advice. Requirements for medical authorizations and childcare protocols vary by jurisdiction. You should consult with qualified legal counsel to ensure this document complies with all applicable local laws and specific personal requirements.