Children’s Emergency Consent Form

If your child/children 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 baby-
sitter, day care center or temporary guardian.

In the event of a medical emergency, the form should accompany your child to the
hospital.

I/We hereby authorize______________________________________________________________

to give

consent for all medical and/or surgical treatment that may be required for our
child/children during our

absence from (date)_________ until (date)_____________.

Child #1: Full Name-_____________________________ Date of Birth-____________

Social Security #-_________________ Medical Record #__________________________

Chronic Illnesses-
________________________________________________________________________

Allergies-________________________________________________________________

Current Medications-______________________________________________________

Date of Last Tetanus Immunization-_____________________

Child #2: Full Name-_____________________________ Date of Birth-____________

Social Security #-_________________ Medical Record #__________________________

Chronic Illnesses-
________________________________________________________________________

Allergies-________________________________________________________________

Current Medications-______________________________________________________

Date of Last Tetanus Immunization-_____________________

Child #3: Full Name-_____________________________ Date of Birth-____________

Social Security #-_________________ Medical Record #__________________________

Chronic Illnesses-
________________________________________________________________________

Allergies-________________________________________________________________

Current Medications-______________________________________________________

Date of Last Tetanus Immunization-_____________________

Child #4: Full Name-_____________________________ Date of Birth-____________

Social Security #-_________________ Medical Record #__________________________

Chronic Illnesses-
________________________________________________________________________

Allergies-________________________________________________________________

Current Medications-______________________________________________________

Date of Last Tetanus Immunization-_____________________

Family Physician/Pediatrician: _________________________ Telephone

#_________________________

Names of Parents/ Legal

Guardian(s)________________________________________________________

Home address of parent/legal

guardian:______________________________________________________

Telephone #’s of parent/legal

guardian:______________________________________________________

Employer: ________________________________ Telephone

#__________________________________

Health Insurance Co._______________________ Member #__________________ Group

#___________

Policy Holder Name: ________________________ Policy Holder Date of Birth:

___________________

Emergency Contact (other than

parent/guardian)_______________________________________________
Telephone#___________________________

Signed: Parent/Legal Guardian________________________________ Date: ______________