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Parental Consent and Contact Form

This form is to be completed and signed by the child’s parent or legal guardian. The signature of the parent or legal guardian indicates permission for the babysitter to follow and act in accordance with these instructions.

Name of Child: ____________________________________________

Date of Birth: ____________

Medical Condition(s) of Concern:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Signs and/or Symptom(s) to Watch for:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

List the Child’s Medications, Prescription and Over-the-Counter:

Medication: ____________________________________________ Dose: ______________

How Given: ____________________________________________ When Given: ____________

Special Instructions (to be taken with, etc.): ____________________________________________

Possible Side Effects: ____________________________________________

Medication: ____________________________________________ Dose: ______________

How Given: ____________________________________________ When Given: ____________

Special Instructions (to be taken with, etc.): ____________________________________________

Possible Side Effects: ____________________________________________

Medication: ____________________________________________ Dose: ______________

How Given: ____________________________________________ When Given: _____________

Special Instructions (to be taken with, etc.): ____________________________________________

Possible Side Effects: ____________________________________________

I give permission for ____________________________________________ ("Babysitter") to administer medicine(s) to the child named above in the manner described above.

Further, I give my permission to the Babysitter to provide basic first aid for the child named above and to take the appropriate measures including contacting the emergency medical services (EMS) system and arranging for transportation to ________________________________________________________ or the nearest medical facility to receive the appropriate level of care as determined by qualified medical professionals.

In the event the child named above is injured or ill, I understand that the Babysitter will attempt to contact me, the other parent or legal guardian at the contact numbers listed below.

Parent/Legal Guardian’s Name: ____________________________________________

Contact Numbers ________________ on ______________ (hours/days)

                                 ________________ on ______________ (hours/days)

                                 ________________ on ______________ (hours/days)

____________________________________________     ____________________
Parent/Legal Guardian Signature                                             Date