Emergency Medical Release This is to authorize______________________________________ to approve whatever emergency medical treatment is necessary for my child, _________________________________, who was born on ___________________. Mother’s Name: Father’s Name: Street Address: City/State/Zip Food Allergies: Medication: Insurance Information: (Include Insurance Provider Name and Phone Number/Member ID, group ID, etc. from the face and back of your insurance card). Home/Work Phone: Work Phone: Email: Cell phone(s) Parent/Custodial Signature:_______________________________________ Date: __________________ Instructions: Complete and leave this form for any authorized childcare provider in case of an emergency situation. If used for the SRMC Babysitting Co-op, be advised that it is the parent’s/custodian’s responsibility to provide this information to each babysitter for each babysitting period. This information will not be provided by the SRMC Babysitting Co-op Coordinators.
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