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http://faculty.deanza.

edu/donahuemary/BabysitterConsentandContactForm

Babysitter Consent and Contact Form


This is from the American Red Cross Infant CPR portion of the 2001 Red Cross First Aid/CPR/AED program. The text says: "This page may be duplicated by individuals and contacts for noncommercial purposes." It's for parents to fill out and leave with the babysitter or designated caregiver. You might want to add information about the child's allergies ( which food, medications, insects), medications (prescription, over-the-counter, herbal), medical conditions (Diabetic? Epilepsy? Asthma?), date of last Tetanus shot, blood type and any recent health problems, surgeries or injuries. You could also specify an alternate contact or two if you can't be reached. Point out the child's Medic Alert tag to the babysitter. Is there a list of important phone numbers next to the phone... vet, family doctor, poison control, trusted neighbor...? Consent and Contact Form This form is to be completed and signed by the child's parent or legal guardian. Name of child:___________________________________________ In the event the child named above is injured or ill, I understand that the caregiver will attempt to contact me, the other parent, or the legal guardian at the telephone number provided below. Parent's (legal guardian's name:______________________ Telephone numbers __________________on ______________(hours/days) ___________________on ___________________(hours/days) Parent's (legal guardian's) name: _______________________ Telephone numbers __________________on ______________(hours/days) ___________________on ___________________(hours/days) In the event that I or the others listed are not available, I give my permission to the caregiver to provide first aid for the child named above and to take the appropriate measures including contacting the emergency medical services (EMS) system and arranging for transportation to ________________________________________

or the nearest emergency medical facility. At no time will the caregiver drive an ill or injured child to an emergency medical facility unless accompanied by another adult. Signature ___________________________ Date _______________ _________________________________________________ Teach your children their basic personal information in case they become separated from care givers. Regularly update your child's school with current health status info, emergency contact info and info as to who is authorised to pick them up Make sure each child (especially those of cell phone use age) knows how to contact your out-ofstate contact person (if you don't understand this concept see: Disaster planning)