Babysitter Medical Release Form

Babysitter Medical Release Form
Valid From:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Valid To:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Information
Child's Name
First NameLast Name
Child's Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Medical Information
Child's Doctor
First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Hospital
Child's Allergies and Medical Conditions
Child's Health Insurance Provider
Policy Number
Parent/Guardian Information
Parent/Guardian Name
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Babysitter Information
Babysitter Name
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Medical Release
In case of an emergency, I give permission to the babysitter to give medical decisions about my child till a parent/guardian is reached out. These medical decisions may include the following:
Parent/Guardian Signature
Clear
Babysitter Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: