Emergency Care Authorization

A medical release form is a document you sign that grants permission to a nanny to look for medical assistance for your minor child or children. This form is necessary since some physicians and other medical personnel will decline to treat a child if permission from the parent or legal custodial has not been plainly stated.

Name of Child (children): ____________________________________________________________

I the undersigned give permission for caring for the above named Child(children) to
{Name of the person(s) who will be caring for the child}
_________________________________________________________________________________

Here is where I can be reached while away including phones and locations.
__________________________________________________________________________________
__________________________________________________________________________________

I hereby authorize the person(s) named above to sign for medical treatment of my child(ren)
between the following dates:
From: __________________ Until: ___________________

Parent Signature: ________________________ Date: ____________________

Witnessed By: ___________________________________________________

Phone: _________________________________________________________

Address: ________________________________________________________

Insurer: __________________________ Number: _______________________

EMERGENCY CARE INFORMATION

Child's full name: _________________________________________________

Date of Birth: __________________ Date last Tetanus Shot: ______________________

Child is allergic to the following medications: _______________________________________ ( ) None

Child is taking the following medications: _________________________________________ _ ( ) None

Child is diabetic, has other chronic condition or major illness:
_____________________________________________________________________________ ( ) None

Name of primary care physician and phone number___________________________________________

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