Sample Emergency Care Authorization

EMERGENCY CARE AUTHORIZATION
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___________________________________________