Free Childcare Form

Emergency Medical Care Authorization

Document emergency contacts, physician information, medical concerns, and parent authorization for emergency care.

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Emergency medical authorization and child health record requirements vary by jurisdiction. Follow applicable childcare licensing, healthcare, and emergency procedures.

Emergency Medical Care Authorization

Childcare Emergency Medical Information

Child Information

Child's Full NameDate of BirthClassroom / GroupChildcare Center

Parent / Guardian

Parent / Guardian NamePrimary PhoneAlternate PhoneWork Phone

Emergency Contacts

Emergency Contact 1RelationshipPhoneEmergency Contact 2RelationshipPhone

Physician / Medical Provider

Physician / ClinicPhone

Allergies

Medical Conditions

Emergency Instructions

Emergency Medical Authorization

If I cannot be reached during a medical emergency, I authorize the childcare program to obtain emergency medical care for my child, including contacting emergency medical services and arranging transportation to an appropriate medical facility when necessary.

I authorize emergency medical careSee written special instructions

Preferred Emergency Facility

Hospital / Emergency FacilityInsurance Provider

Parent / Guardian Signature

Date

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