Free Child Care Medical Authorization Form

Please complete this form to grant medical authorization for your child while under the care of a caregiver.
Child's Information
Name
Date of Birth
Allergies/Medical Conditions
Medications
Parent/Guardian Information
Name
Phone number
Emergency Contact Information
Name
Phone number
Relationship to Child
Medical Authorization
I hereby grant permission for my child to receive medical treatment in case of an emergency while under the care of the designated caregiver. I authorize the caregiver to seek medical attention, including calling an ambulance or taking my child to the nearest hospital if necessary.
Parent/Guardian Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
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