emergency contact form for babysitter pdf

Childcare Emergency Information and Authorization Form

Instructions for Use

• Complete all fields below clearly and legibly, ensuring that medical and contact information is current and accurate.
• Provide a copy of this document to the primary caregiver and keep an additional copy in a secure, accessible location within the home.
• Review and update this information periodically, specifically prior to any change in the household or the caregiver’s responsibilities.

Parties and Definitions

This document is entered into by the Parent/Guardian [] (the "Parent") and the Caregiver [] (the "Caregiver") regarding the supervision of the following minor(s):

1. [] (DOB: [])
2. [] (DOB: [])

Operative Clauses

1. Emergency Contact Information: In the event of an emergency, the Caregiver shall contact the Parent at [] or []. If the Parent is unreachable, the Caregiver is authorized to contact:

   • [Name]: [] | [Phone]: []
   • [Name]: [] | [Phone]: []

2. Medical Authorization: The Caregiver is authorized to act on behalf of the Parent to consent to necessary medical treatment for the minor(s) if the Parent cannot be reached. This includes, but is not limited to, emergency room visits, diagnostic tests, and surgical procedures deemed necessary by a licensed physician.

   • Physician Name: [__________]
   • Physician Phone: [__________]
   • Preferred Hospital: [__________]

3. Allergies and Dietary Restrictions: The minor(s) have the following known allergies or dietary restrictions: [] []

4. Medication Administration: The Caregiver is authorized to administer the following medications according to the instructions provided:

   • Medication: [] Dosage: [] Time: [__________]
   • Medication: [] Dosage: [] Time: [__________]

5. Insurance Information:

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

6. House Rules and Limitations: The Caregiver agrees to adhere to the following household policies:

   • No visitors allowed.
   • Swimming/Water access restricted.
   • Screen time limit: [__________] minutes.
   • Bedtime: [__________] PM.

Signature and Acknowledgment

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

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

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

Legal Disclaimer: This document serves as a general framework for informational purposes only. It does not constitute legal advice. Users should consult with qualified legal counsel to ensure compliance with specific state or local laws regarding medical consent and childcare liability.