Babysitter Medical Consent Form – Fill Out and Use This PDF

A Babysitter Medical Consent Form is a document that grants a babysitter or child care provider the authority to make medical decisions for a child or children under their care in the event of an emergency when the parent or guardian cannot be reached.

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Babysitter Medical Consent PDF Details

This form provides essential information about the child or children, including their medical history, allergies, medications, and insurance information. It also includes the contact information of the parents or guardians, as well as the caregiver who is authorized to make medical decisions for the child or children in the parents' or guardians' absence.

This form is essential for babysitters or child care providers, as it allows them to act in the best interest of the child or children in their care during emergencies, without having to wait for parental consent.

Question	Answer
Form Name	Babysitter Medical Consent Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	5
Avg. time to fill out	1 min 30 sec
Other names	medical authorization form for babysitter, letter for babysitter for emergency care, medical release for babysitter, babysitter consent to treat form

12

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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