Emergency Child Care Form

form to use to authorize baby sitter or other care taker to make emergency medical decisions for child in his or her care DONE

AUTHORIZATION

______________________ (Name of Parents) hereby authorize ______________________________

to obtain medical treatment for______________________ (Name of child) for the period

__________________________ to _______________________.

_________________________________

Signature of Parent

__________________________________

Signature of Parent

Sworn to before me this _____ day of __________, 20__

________________________________ (Notary Public)

Name of Child's Doctor: _______________________ Telephone Number: ____________________

nsurance company: _______________________________

Policy Number: __________________________ Insured: _________________________________