I hereby 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 child's health.
In case of emergency, and if emergency transportation is needed, I........................................................... agree to pay all costs of transportation.
Child's physician:...................................................................................................................................
Physician's address:............................................................................................................................
Preferred hospital:.................................................................................................................................
Hospital address:.....................................................................................................................................
Clinic or Hospital phone number:....................................................................................................
Medical insurance:..................................................................................................................................
Insurance numbers:...............................................................................................................................
Date of last tetanus (or DPT):........................................................................................................ Allergies:........................................................................................................................................................
Father's name:...............................................................
Mother's name:...............................................................
Father's signature:.............................................................................Date:..............................
Mother's signature:............................................................................Date:..............................