Authorization for Medical Treatment of a Minor Child

Kidsit babysitting forms

This form has been filled out by me to designate temporary authority for my child’s

babysitter ____________________________ to obtain any necessary medical care

for my child in the event I am unable to be reached for permission.

This care would encompass any emergent or urgent care required for the health and

safety of my child. If I have not already called this office/clinic/hospital prior to the

visit to give my explicit instructions, every attempt should be made to contact me

before care is given unless it is a life-threatening emergency.

Please ask my babysitter for identification before authorizing any treatment

for my child.

Child’s full name: ______________________________ Date of birth: _____________

Home address: ________________________________________________________

Parent’s name: ________________________________ Phone #: ________________

Babysitter’s name: _____________________________ Phone #: ________________

Time period this authorization will be in effect: _____________ to ______________

Physician: ___________________________________ Phone #: ________________

Specialist: ___________________________________ Phone #: ________________

Dentist: ______________________________________ Phone #: ________________

Child’s medications: ____________________________________________________

Child’s medical conditions: _______________________________________________

Child’s allergies: __________________ Date of last tetanus booster: ___________

Health insurance: ________________ Phone: __________ Group #: ____________

I acknowledge that I am responsible for all reasonable charges in connection with

my child’s treatment.

Signature: ________________________________________ Date: _____________

Witness: ________________________________________ Date: _____________