Fillable Child Care Provider Medical Consent Form

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Child Care Provider Medical Consent Form

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The Child Care Provider Medical Consent Form form is 2 pages long and contains:

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  • 4 check-boxes
  • 4 other fields

Country of origin: OTHERS
File type: PDF

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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:________________________
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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Child Care Provider Medical Consent Form

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Completed 15 June 2021

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