If your child needs emergency medical care and you aren't available to give formal consent to medical authorities, care may be unnecessarily delayed. To protect your child, leave a completed EMERGENCY CONSENT FORM with your child care provider or temporary guardian. In the event of a medical emergency, the form should accompany your child to the hospital so that medical treatment can be rendered. You may want to keep a completed form (authorizing a licensed medical doctor to give consent) in your baby's diaper bag for an extra measure of safety. Make copies of this blank form to share with a friend, and to have extras readily available.

I/We hereby authorize _________________________to give consent for all medical and/or surgical treatment that may be required for our child during our absence from___________until___________. (Consent expires one year from this date)

Child's Name:
Chronic Illnesses:
Allergies:
Current Medications:
Date of Last Tetanus Immunization:
Other:

Physician:
Telephone:
Home address of parent/guardian:
Telephone number of parent/guardian:
Additional telephone numbers:
Employer:
Telephone:
Health insurance co:
Member number:
Group number:
Nearest relative:
Telephone:
Additional relative:
Telephone:

Signed, parent/guardian:
Date: