Caretaker Medical Consent Form - Day Care Business


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									This Caretaker Medical Consent Form (Day Care Business) should be used by any
legal guardian when he or she is leaving a child in the care of a day care business. This
form allows a caretaker to access medical treatment for the child without delay, which is
critical in emergency situations. This document includes a section for the medical
information of the minor. The specific details with regard to scope and duration of
consent can be customized and inserted into this consent form.
              Caretaker Medical Consent Form (Day Care Business)
                   (This form must be signed unaltered at least once per year)

       As a condition of receiving babysitting from __________________ [Instruction: insert
name of Caretaker] (“CARETAKER”) or its affiliates, and in consideration thereof, the
undersigned person, on behalf of my __________________ [Instruction: insert relationship],
__________________ [Instruction: insert name of minor] (“Minor”), hereby represents,
warrants and covenants as follows (the "Agreement"):

1. Consent to Medical Care Including Emergency Treatment. I authorize first aid treatment
   by CARETAKER and others, and any medical treatment by qualified medical doctors in the
   event of a medical emergency which, in the opinion of the medical doctors, may endanger
   Minor’s life, cause disfigurement, physical impairment, or undue discomfort. I consent to
   CARETAKER arranging for emergency medical and/or dental care and treatment necessary
   to preserve the health of Minor, including arranging for transportation to the nearest
   emergency room. In the event of an emergency, the CARETAKER shall take reasonable
   steps to contact me before medical treatment is administered. I understand that I am
   accountable for all reasonable fees related to the care and treatment rendered to Minor during
   this period. This consent shall expire on __________________ [Instruction: insert date].

[Comment: user may edit the medical treatments for which authorization is provided]

2. Authority/General. I further state that I am of lawful age and legally competent to
   sign this consent form. I have carefully reviewed this form, fully understand the
   terms and conditions hereof, and have had the opportunity to consult with legal
   representation prior to entering into this Agreement. Further, I certify that there is
   no court order that would prevent me from legally making such an authorization.

3. Medical Information.

    Health Insurance Carrier __________________ [Instruction: insert date].

    Health Insurance Policy # __________________ [Instruction: insert policy number] and
    Group # __________________ [Instruction: insert group insurance number].

    Minor’s Personal Care Physician __________________ [Instruction: insert name of
    personal care physician].

    Address __________________________________________ [Instruction: insert complete

    Phone __________________ [Instruction: insert phone].
    Minor’s Dentist __________________ [Instruction: insert name of dentist].

    Address __________________________________________ [Instruction: insert complete

    Phone __________________ [Instruction: insert phone].

    Minor’s Allergies __________________ [Instruction: insert all allergies of Minor].

    Date of last tetanus booster __________________ [Instruction: insert date].

    Current Medications __________________ [Instruction: insert all medications that the
    Minor is currently taking].

Signature of Legal Guardian __________________ [Instruction: insert signature].

Name __________________ [Instruction: insert name].

Date __________________ [Instruction: insert date of signature].

Address __________________________________________ [Instruction: insert complete

Phone __________________ [Instruction: insert date].

STATE OF __________________ [Comment: user should get this consent form notarized]
COUNTY OF __________________

Before me, the undersigned authority, on this day personally appeared ________________
[Instruction: insert legal name], known to me to be the person whose name is subscribed to the
foregoing instrument, and upon his or her oath acknowledged to me that he or she executed the
same for the purposes and consideration therein expressed and in the capacity therein stated.

____________, 20__________.


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