Medical Release Form for Babysitter

June 30, 2011

A medical release form for babysitter enables your babysitter to seek medical help for your child when you are not available or when you are unreachable by phone.  The medical release form for babysitter is an important form as most doctors and medical practitioners will not treat your child without it.

Sample Medical Release Form for Babysitter


Please indicate details concerning the child who is below 18 years of age:

Name of child: _____________________ Date of birth: ________________________

Name of insurer: ___________________ Policy number: _______________________

Parent’s name: _____________________ Tel no: _____________________________

Name of child’s pediatrician: __________________ Tel no: _________________

Please indicate any and all of your child’s allergies:

________________________________________________________________________

________________________________________________________________________

I ___________________ (name of parent) do hereby acknowledge that I have given

consent to ___________________________ (name of babysitter) to seek medical help

for my child _______________________ (name of child) in my absence, when I am not

reachable.

Parent’s Sig: ___________________ Date: _______________

Name of witness: ___________________ Sig: ______________

 

Download Medical Release Form for Babysitter in Word Format

Leave a Comment

Previous post:

Next post: