Babysitters Medical Release forms are used to authorize babysitters to act on behalf of the guardian in cases of medical emergencies. The form is filled and signed by the guardian and contains important information about the child including Insurance policy numbers and personal physicians. A Sample Babysitters Medical Release form is below.
Sample Babysitters Medical Release Form
I _____________________________ (Parent or Guardian) hereby give permission for any medical attention to be administered to my child _____________________ (child’s name) in the event of an accident or any medical emergency under the direction of the person (s) listed below until I am contacted. I take responsibility over any payments that will be incurred. This release is for the period of six months from the date indicated below.
Address _____________________________________________________________
___________________________________________________________________
Insurance Company____________________________________________________
Policy Number ________________________________________________________
In case I cannot be reached, the following person can act on my behalf:
Babysitter___________________________________________________________
Physician: ___________________________________________________________
Address: ___________________________________________________________
Phone: _____________________________________________________________
Allergies: ___________________________________________________________
Signature (Parent/Guardian) ________________ ___Date ____________________
Signature of authorizing Persons ___________________ Date _________________
(Notary Public)
