Local, vetted babysitters all year round

medical release form

Parent/Legal Guardian

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Email Address

Alternate Person to Contact

In case of emergency

Relationship to Child

Alternate Person's Phone Number

(###)

###

####

CHILD ONE

Name

First Name

Last Name

Date of Birth

Medical History

Allergies, disabilities, over the counter and/or prescription drugs taken regularly, etc.

CHILD TWO

Name

First Name

Last Name

Date of Birth

Medical History

Allergies, disabilities, over the counter and/or prescription drugs taken regularly, etc.

CHILD THREE

Name

First Name

Last Name

Date of Birth

Medical History

Allergies, disabilities, over the counter and/or prescription drugs taken regularly, etc.

CHILD FOUR

Name

First Name

Last Name

Date of Birth

Medical History

Allergies, disabilities, over the counter and/or prescription drugs taken regularly, etc.

Other Information

List any additional medical history, behavioral issues or other information you would like us to be aware of

If I cannot be contacted, I give permission to the Summer Sitters, LLC babysitter(s), any responding ambulance service, personal physician and dentist, and/or hospital to provide emergency treatment and/or hospitalization for my child in the event of illness or an injury. I understand that I will be responsible for all charges, fees, and expenses incurred in the rendering of such emergency medical treatment.

Signature of Parent/Legal Guardian

I agree that my name typed above is to be used as my electronic signature

Agree

medical release form

DOWNLOAD THE SUMMER SITTERS APP TODAY!