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©Nakali Consulting, Inc 2010 l Emergency Medical Consent Form
EMERGENCY MEDICAL CONSENT FORM
_________________________________________________ has my permission to obtain
emergency medical treatment for my child, ________________________________________
when I cannot be reached or if a delay in reaching my child would be dangerous for him/her.
Mother/Guardian’s Name _____________________________________________________
Home Phone _________________________ Cell Phone _________________________
E-mail Address: ______________________________________________________________
Father/Guardian’s Name______________________________________________________
Home Phone _________________________ Cell Phone _________________________
E-mail Address: ______________________________________________________________
My insurance provider is _______________________________________________________
My child’s medical record number is _____________________________________________
Preferred hospital/treatment center ______________________________________________
My child is taking the following medications
_________________________ ______________________ ______________________
My child has the following allergies
_________________________ ______________________ ______________________
I understand that I assume all financial responsibility for any treatment or injuries sustained
by my child while he/she is in child care.
_______________________________________ _________________
Signature of Parent or Guardian Date
_______________________________________ _________________
Signature of Parent or Guardian Date