Make a copy of the forms below for each person or agency that takes care of your child. This can include relatives, baby-sitters, day care providers, pre-schools, schools, and after school sports or activities. Print the form and fold it in half.

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Consent to Treat Form

Parent name: ____________________________

Address: ________________________________

City/State: ______________________________

Home Phone: ____________________________

Cell: _______________ Pgr: _______________

Emergency number: _______________________

Child's Name: ___________________________

Date of Birth: ____________________________

Medical provider: _________________________

Medical number: _________________________

Medications: ____________________________

_______________________________________

Allergies: _______________________________

_______________________________________

Special Medical Problems: __________________

_______________________________________

I authorize ________________________ to act on my behalf in obtaining medical care for

_______________________________________

Signature: ______________________________

Date: __________________________________

Emergency Information

Emergency Service

911 or __________________________________

Local Emergency Room

Hospital Name: ___________________________

Address: ________________________________

Phone: _________________________________

Local Hospital

Name: __________________________________

Address: ________________________________

Phone: _________________________________

Local Children's Hospital

Name: __________________________________

Address: ________________________________

Phone: _________________________________

Pediatrician

Name: __________________________________

Address: ________________________________

Phone: _________________________________

Poison Control _________________________

Local Advice Line _______________________