I herby give permission for my child/children ....................................................................................................
may be given emergency treatment (first aid and CPR) by a qualified staff member at xxxxx Day Care.

I also give my permission for my child/children to be transported by ambulance, aid car, or staff car to an emergency center for treatment.

In the event that I cannot be contacted, I further consent to the medical, surgical, and hospital care treatment and procedures to be performed for my child by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard my childís health.

In case of emergency, and if emergency transportation is needed, I........................................................... agree to pay all costs of transportation.

Childís physician:...................................................................................................................................
Physicianís address:............................................................................................................................

Preferred hospital:.................................................................................................................................
Hospital address:.....................................................................................................................................
Clinic or Hospital phone number:....................................................................................................

Medical insurance:..................................................................................................................................
Insurance numbers:...............................................................................................................................

Date of last tetanus (or DPT):........................................................................................................ Allergies:........................................................................................................................................................

Fatherís name:...............................................................
Motherís name:...............................................................
Fatherís signature:.............................................................................Date:..............................
Motherís signature:............................................................................Date:..............................