Emergency Medical Form - The Daycare Lady
Emergency Medical Form
This authorizes (YOUR NAME), Home Daycare Provider, to secure EMERGENCY medical care for my child: _________________________________
When I/We cannot be immediately reached at the time of the emergency. I/We will be responsible for the emergency medical charges upon receipt of the statement.
____________________________________is the preferred doctor/hospital/clinic.
Mother's Signature: ______________________ Date: ________________
Father's Signature: ______________________ Date: _________________
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