| Little Steps Childcare Medical Emergency Consent Name of Child _____________________________ Health Card # _____________________________ Mother�s Name ____________________________ Home Phone # __________________ Work Phone # ______________ Father�s Name _____________________________ Home Phone # __________________ Work Phone # _______________ Name of Child�s Doctor_________________________________________ Phone Number of Child�s Doctor _______________________________ When there is a medical emergency, or when a child needs immediate medical treatment, the provider will take all reasonable steps to see that the children in her care receive adequate medical care. When appropriate, the provider will call 911 and the parents. If the parents cannot be reached, the provider will call the persons listed below who are authorized by the parent to give permission for the medical treatment of the child. These persons authorized to do so are: Name __________________________ Phone # ________________ Name __________________________ Phone # ________________ If the parents and the authorized persons cannot be reached, the provider will call the child�s doctor, identified above. If the child must be taken to the hospital, the provider will take the child to the child�s hospital identified above. If under the circumstances it is more reasonable to bring the child to another hospital, the provider will do so. In the situation where the parents and the persons authorized to give permission for medical treatment cannot be reached; the parent authorizes the child�s doctor to provide the appropriate medical treatment for the child. Provider�s Signature_______________________ Date ______________ Mother�s Signature________________________ Date _______________ Father�s Signature ________________________ Date _______________ |
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