Caregiver Contract

Step 1 of 23

User Email*
Who is the Parent/Guardian providing consent/authorization?
Personal Title:
Name
Relationship to Child(ren):
Where is the Parent/Guardian's place of address?
Address
Address: City State: Zip Code:

How can the Parent/Guardian be contacted?
Primary Phone Number:
Alternate Phone Number:
Email Address:
When will this Medical Consent form be signed?
Authorization Date:
MM slash DD slash YYYY
Who is the Child this form is being created for?
Child Name:
Child Date of Birth:
MM slash DD slash YYYY

Where is the Child's place of address?
Address
Address: City: State: ZIP Code:
What is the Child's phone number?
Phone Number (if applicable):

Please provide the following medical information for the Child.
Enter below any known allergies that the child may have:
Enter below any known medical conditions the child may have:
Enter below any medications the child is currently taking:

Include a Second Child under this Medical Consent form?
Include a second child?:
- Yes
- No
Child Name:
Child Date of Birth:
MM slash DD slash YYYY

What is the second child's address and telephone number?
Address
Address: City: State: ZIP Code:

What is the second child's telephone number?
Phone Number (if applicable):
Please provide the following medical information for the second child.
Enter below any known allergies that the child may have:
Enter below any known medical conditions the child may have:
Enter below any medications the child is currently taking:

Include a Third Child under this Medical Consent form?
Include a third child?:
- Yes
- No
Child Name:
Child Date of Birth:
MM slash DD slash YYYY

Where is this Child's place of address?
Address
Address: City: State: ZIP Code:
What is this Child's phone number?
Phone Number (if applicable):

Please provide the following medical information for this Child.
Enter below any known allergies that the child may have:
Enter below any known medical conditions the child may have:
Enter below any medications the child is currently taking:

Include a Fourth Child under this Medical Consent form?
Include a fourth child?:
- Yes
- No
Child Name:
Child Date of Birth:
MM slash DD slash YYYY

Where is this Child's place of address?
Address
Address: City: State: ZIP Code:

What is this Child's phone number?
Phone Number (if applicable):

Please provide the following medical information for this Child.
Enter below any known allergies that the child may have:
Enter below any known medical conditions the child may have:
Enter below any medications the child is currently taking:

Who is the Primary Child Care Provider?
Care Provider Name:
Provider Relationship to Child:
Provider Home/Word Telephone Number:
Provider Cell Phone Number:
Is there an Alternate Child Care Provider?
Add alternate care provider?:
- Yes
- No

What is the name and contact information of the alternate child care provider?
Alternate Care Provider Name:
Alternate Provider Relationship to Child:
Alternate Provider Home/Word Telephone Number:
Alternate Provider Cell Phone Number:
Alternate Provider Email Address:

Who is the First Emergency Contact?
First Emergency Contact Name:
First Emergency Contact Relationship to Child:
First Emergency Contact Home/Work Telephone:
First Emergency Contact Cell Phone Number:
First Emergency Contact Email Address:

Is there a Second Emergency Contact?
Include a second emergency contact in this consent form?:
- Yes
- No

What is the name and contact information of the second emergency contact that you authorize to approve emergency medical/dental care for your child?
Second Emergency Contact Name:
Second Emergency Contact Relationship to Child:
Second Emergency Contact Home/Work Telephone:
Second Emergency Contact Cell Phone Number:

Please provide health insurance information for the child included in this form.
First Insurance Company Name:
Policy Number:
Group Number:

Is the child covered under another health insurance policy?
Add another health insurance policy?:
- Yes
- No

What is the child's second health insurance information?
Second Insurance Company Name:
Policy Number:
Groupt Number:

What is the name and contact information of the child's primary care physician?
Physician Name:
First
Physician Address: City State ZIP Code:
Physician Telephone Number:

MEDICAL & DENTAL RELEASE FORM FOR MINOR

I, ${input_57_3} . ${input_57_4} , certify that I am the parent or legal guardian of the minor listed below, and as such, I hereby convey temporary authority to the below designated adults for the sole purpose of obtaining or arranging any emergency medical or dental care for the minor as may be deemed necessary for the well-being of my when not accompanied by a parent/legal guardian or should either parent/legal guardian be unreachable by telephone.

BE IT FURTHER KNOWN THAT I hereby releases any licensed health care provider providing medical care to the minor listed below in reliance of this form from liability relating to such provider's acceptance of my substitute care giver's consent.

THEREFORE, I hereby approve and empower the below listed individuals with the authority to arrange and/or consent for any and all emergency medical/dental care and treatment of my in my absence.

_____________________________ (Signature of Parent/Legal Guardian)	${input_57_10} _____________________________ (Date)
${input_57_4} _____________________________ (Name of Parent/Legal Guardian)	${input_57_8} _____________________________ (Relationship to )
${input_57_132} _____________________________ (Home/Work Number)	${input_57_134} _____________________________ (Cell Number)

MINOR

Child's Name: ${input_57_13} :

Address: ${input_57_18_1} , ${input_57_18_3} , ${input_57_18_4} ${input_57_18_5}

Telephone Number: ${input_57_21} :

Date of Birth: ${input_57_14} :

Parent/Legal Guardian: ${input_57_4}

Address: ${input_57_5_1} , ${input_57_5_3} , ${input_57_5_4} ${input_57_5_5}

Home/Work Telephone: ${input_57_132}

Cell Telephone: ${input_57_134}

Allergies:

Medical Conditions:

Current Medications:

PRIMARY CHILD CARE PROVIDER

${input_57_78} _____________________________ (Primary Child Care Provider Name)	${input_57_79} _____________________________ (Relationship to Minor Child)
${input_57_80} _____________________________ (Home/Work Telephone Number)	${input_57_81} _____________________________ (Cell Phone Number)

AUTHORIZED EMERGENCY CONTACTS

${input_57_94} _____________________________ (Emergency Contact Name)	${input_57_95} _____________________________ (Relationship to Minor Child)
${input_57_96} _____________________________ (Home/Work Telephone Number)	${input_57_97} _____________________________ (Cell Phone Number)

HEALTH INSURANCE & DOCTOR INFORMATION

Insurance Company: ${input_57_110}

Policy Number: ${input_57_111}

Group Number: ${input_57_112}

Physician's Name: ${input_57_124_3}

Address: ${input_57_125_1} , ${input_57_125_3} , ${input_57_125_4} ${input_57_125_5}

Telephone Number: ${input_57_126}

MEDICAL & DENTAL RELEASE FORM FOR MINOR

_____________________________ (Signature of Parent/Legal Guardian)	${input_57_10} _____________________________ (Date)
${input_57_4} _____________________________ (Name of Parent/Legal Guardian)	${input_57_8} _____________________________ (Relationship to )
${input_57_132} _____________________________ (Home/Work Number)	${input_57_134} _____________________________ (Cell Number)

MINOR

Child's Name: ${input_57_13} :

Address: ${input_57_18_1} , ${input_57_18_3} , ${input_57_18_4} ${input_57_18_5}

Telephone Number: ${input_57_21} :

Date of Birth: ${input_57_14} :

Parent/Legal Guardian: ${input_57_4}

Address: ${input_57_5_1} , ${input_57_5_3} , ${input_57_5_4} ${input_57_5_5}

Home/Work Telephone: ${input_57_132}

Cell Telephone: ${input_57_134}

Allergies:

Medical Conditions:

Current Medications:

PRIMARY CHILD CARE PROVIDER

${input_57_78} _____________________________ (Primary Child Care Provider Name)	${input_57_79} _____________________________ (Relationship to Minor Child)
${input_57_80} _____________________________ (Home/Work Telephone Number)	${input_57_81} _____________________________ (Cell Phone Number)

AUTHORIZED EMERGENCY CONTACTS

${input_57_94} _____________________________ (Emergency Contact Name)	${input_57_95} _____________________________ (Relationship to Minor Child)
${input_57_96} _____________________________ (Home/Work Telephone Number)	${input_57_97} _____________________________ (Cell Phone Number)

HEALTH INSURANCE & DOCTOR INFORMATION

Insurance Company: ${input_57_110}

Policy Number: ${input_57_111}

Group Number: ${input_57_112}

Physician's Name: ${input_57_124_3}

Address: ${input_57_125_1} , ${input_57_125_3} , ${input_57_125_4} ${input_57_125_5}

Telephone Number: ${input_57_126}

Caregiver Contract

Step 1 of 23

Who is the Parent/Guardian providing consent/authorization?

Where is the Parent/Guardian's place of address?

How can the Parent/Guardian be contacted?

When will this Medical Consent form be signed?

Who is the Child this form is being created for?

Where is the Child's place of address?

What is the Child's phone number?

Please provide the following medical information for the Child.

Include a Second Child under this Medical Consent form?

What is the second child's address and telephone number?

What is the second child's telephone number?

Please provide the following medical information for the second child.

Include a Third Child under this Medical Consent form?

Where is this Child's place of address?

What is this Child's phone number?

Please provide the following medical information for this Child.

Include a Fourth Child under this Medical Consent form?

Where is this Child's place of address?

What is this Child's phone number?

Please provide the following medical information for this Child.

Who is the Primary Child Care Provider?

Is there an Alternate Child Care Provider?

What is the name and contact information of the alternate child care provider?

Who is the First Emergency Contact?

Is there a Second Emergency Contact?

What is the name and contact information of the second emergency contact that you authorize to approve emergency medical/dental care for your child?

Please provide health insurance information for the child included in this form.

Is the child covered under another health insurance policy?

What is the child's second health insurance information?

What is the name and contact information of the child's primary care physician?