Babysitter Consent To Treat Form Details

Below is the information in regards to the file you were looking for to complete. It will tell you just how long it will require to complete medical consent form babysitter, what fields you will need to fill in, etc.

QuestionAnswer
Form NameMedical Consent Form Babysitter
Form Length2 pages
Fillable?Yes
Fillable fields5
Avg. time to fill out1 min 30 sec
Other namesmedical release form for babysitter, babysitter medical release form, babysitter medical consent form, medical consent form for babysitter

Form Preview Example

Child Care Provider Medical Consent Form

Valid from (date) to (date)

Child 1 Information

 

Child’s Name:__________________________

Child’s Date of Birth:_____________

Child’s Doctor:__________________________

Doctor’s Phone Number:__________

Preferred Hospital: ______________________

 

Child’s Allergies and Medical Conditions: _____________________________________

Child’s Past Surgeries:____________________________________________________

Child’s Medications:______________________________________________________

Child’s Health Insurance Provider:______________

Policy Number:_______________

Child 2 Information

 

Child’s Name:__________________________

Child’s Date of Birth:_____________

Child’s Doctor:__________________________

Doctor’s Phone Number:__________

Preferred Hospital: ______________________

Child’s Allergies and Medical Conditions: _____________________________________

Child’s Past Surgeries:____________________________________________________

Child’s Medications:______________________________________________________

Child’s Health Insurance Provider:______________

Policy Number:_______________

Child 3 Information

 

Child’s Name:__________________________

Child’s Date of Birth:_____________

Child’s Doctor:__________________________

Doctor’s Phone Number:__________

Preferred Hospital: ______________________

 

Child’s Allergies and Medical Conditions: _____________________________________

Child’s Past Surgeries:____________________________________________________

Child’s Medications:______________________________________________________

Child’s Health Insurance Provider:_________ Policy Number:______ Policy Number:_______

Parent/Guardian Information

Custodial Parent/Guardian Name(s):__________________ Phone Number:________________

Address:______________________________________________________________________

Custodial Parent/Guardian Name(s):__________________ Phone Number:________________

Address:______________________________________________________________________

Caregiver Information

In the case that no parent/guardian can be reached, please allow the following named individual to make medical decisions for the above named child/children:

Caregiver’s Full Legal Name:______________________________ Date of Birth:____________

Address:______________________________________________ Phone Number:__________

Relationship to Child:________________________

https://baby.lovetoknow.com/wiki/Babysitter_Medical_Consent_Form

Minor Medical Consent

In case of an emergency, I grant permission to (caregiver's full legal name) to make medical decisions for my child/children until one parent/guardian can be reached. Medical decisions I authorize the above named individual to make include:

Sharing personal information about my child/children with emergency personnel. Authorizing use of life-saving medical devices.

Authorizing use of an ambulance for transport.

Other:__________________________________________________________

_______________________________________________________________

Parent/Guardian Name:___________________ Signature:____________ Date:____________

Witness Name:__________________________ Signature:____________ Date:____________

Parent/Guardian Name:___________________ Signature:____________ Date:____________

Witness Name:__________________________ Signature:____________ Date:____________

In case of an emergency, I agree to make medical decisions for the above named child/children until one parent/guardian can be reached.

Caregiver Name:_____________ Signature:____________ Date:________ Witness:________

Witness Name:______________ Signature:____________ Date:________

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 medical consent letter for babysitter blanks to fill in

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