Isabella’s Child Care
40 Brookline Ave.
Middletown, NY 10940
(845)344-1308 A FUN PLACE TO BE
_______________________________________________________________________________________________________________
EMERGENCY CARE CONSENT FORM
TO BE NOTARIZED
AUTHORIZATION TO CONSENT TO TREATMENT OF A CHILD
I ______________________________, the parents of___________________________
(Name of parent) (Name of child)
Authorize ____________________________ to obtain medical care for my child in
case on emergency. My permission is given to any hospital or doctor to treat my
child in case of emergency.
Permission for treatment will only be given if I can not be contacted or if immediate
treatment is warranted at the discretion of the attending medical person.
Name of parent(s):________________________, ____________________________.
Address: ______________________________ City: _________________
Cell #:____________________________ Other: __________________________
Child’s Age: ___________________ Date of Birth: ________________________
Is your child allergic to Penicillin? _____________________________________
Describe any known allergies or medical condition: ___________________________
_______________________________________________________________________.
Child’s Pediatrician: _______________________ Phone#:_____________________
Signed: ______________________
(Parent)
Date: ______________________
NOTARY SEAL: ____________________
NAME OF INSURED: ________________________________________
INSURANCE COMPANY NAME: _____________________________
POLICY #:__________________________________________________