EMERGENCY MEDICAL CONSENT FORM WITH TEMPLATESHUNTER

EMERGENCY MEDICAL CONSENT FORM

  _________________________________________________ has my permission to obtain 

emergency medical treatment for my child, ________________________________________

when I cannot be reached or if a delay in reaching my child would be dangerous for him/her. 


Mother/Guardian’s Name _____________________________________________________ 

Home Phone _________________________      Cell Phone _________________________ 

E-mail Address: ______________________________________________________________

Father/Guardian’s Name______________________________________________________ 

Home Phone _________________________      Cell Phone _________________________ 

E-mail Address: ______________________________________________________________

  My insurance provider is _______________________________________________________     My child’s medical record number is _____________________________________________      Preferred hospital/treatment center ______________________________________________    My child is taking the following medications 

_________________________     ______________________     ______________________    My child has the following allergies 

_________________________     ______________________     ______________________          I understand that I assume all financial responsibility for any treatment or injuries sustained   by my child while he/she is in child care.   


_______________________________________               _________________  Signature of Parent or Guardian                                Date 


_______________________________________               _________________  Signature of Parent or Guardian                                Date