Consent For Emergency Medical Treatment

As the parent or authorized representative, I hereby give consent to [INSERT BUSINESS NAME] to obtain

all emergency medical or dental care prescribed by a duly licensed physician (m.d.) osteopath (d.o.) or dentist

(d.d.s.) for (Child’s Name) ____________________________________ Birth Date ________________. This

care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child

named above. Child has the following medication allergies and/or medical conditions: ___________________

________________________________________________________________________________________

the care and protection of my child while under their supervision. (D) In case of a medical emergency, I

understand that my child may be transported to [INSERT NEAREST HOSPITAL] by [INSERT YOUR

NAME(S)], or by ambulance for treatment, and if the arriving EMT/Paramedics deem it necessary. (E) In the

event of an accidental ingestion, I understand that [INSERT YOUR NAME(S)] will contact the Poison

Control Center. I grant permission to [INSERT YOUR NAME(S)] to follow whatever directions are given by

Poison Control. (F) I hereby authorize [INSERT YOUR NAME(S)] to act on my behalf in case of an

emergency.

Emergency information is kept on file at the daycare. In case of illness or injury this information will be used

to notify you or the person designated by you, of your child's status. If your child is injured while at the