Child Care Authorization 193135138

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Child Care Authorization 193135138 Powered By Docstoc
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                             Child Care Authorization

IMPORTANT:
Please answer ALL fields. If a question does not apply to you, state “NA” or “not
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                                    FATHER
Name:



Address




City                              State                      Postal/ZIP Code




Phone                              Fax                             Email



                                   MOTHER
Name:




Address




City                              State                      Postal/ZIP Code
Phone          Fax                    Email



                 CHILD
                Child #1
Name:




Age:                  Birthday:


                Child #2
Name:




Age:                  Birthday:


                Child #3
Name:




Age:                  Birthday:

          CHILD CARE PROVIDER
Name:



Address



City          State               Postal/ZIP Code




Phone          Fax                    Email
The child care provided is:
        ☐ an individual
         ☐ a corporation
                                       AUTHORITY
Authority Starts On:                             Authority Ends On:




Seek appropriate medical treatment or attention on behalf of the Minor Children as may
be required by the circumstances, including but not limited to, medical doctor and/or
hospital visits.
                       ☐ Yes               ☐ No

Authorize medical treatment or medical procedures in an emergency situation.
                       ☐ Yes               ☐ No

Make appropriate and necessary decisions regarding clothing, bodily nourishment, and
shelter.
                       ☐ Yes               ☐ No

Explain absences from school; pick minor child/children from school.
                       ☐ Yes               ☐ No

Sign release forms for sports and field trips.
                       ☐ Yes               ☐ No

Other Authority Given to Child Care Provider:




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posted:8/29/2012
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