medical release form

Parent/Legal Guardian *
Parent/Legal Guardian
Home Address
Home Address
Phone Number
Phone Number
In case of emergency
Alternate Person's Phone Number *
Alternate Person's Phone Number
Child one
Name *
Name
Allergies, disabilities, over the counter and/or prescription drugs taken regularly, etc.
Please include: doctor's name, doctor's phone number, health insurance provider and policy number
Child Two
Name *
Name
Allergies, disabilities, over the counter and/or prescription drugs taken regularly, etc.
Please include: doctor's name, doctor's phone number, health insurance provider and policy number
CHILD THREE
Name *
Name
Allergies, disabilities, over the counter and/or prescription drugs taken regularly, etc.
Please include: doctor's name, doctor's phone number, health insurance provider and policy number
Or other issues you would like the babysitter 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.
I agree that my name typed above is to be used as my electronic signature *