(Must be handed to sitter completed)

Where you will be: ______________________________________________________________________

Full Name & birthday(s) of Child(ren)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Known Allergies: _______________________________________________________________________

Approx Weight (include date) ____________________________________________________________

______________________________________________________________________________________

Pager or cell phone or number w/area code where you can be reached: _____________________________

______________________________________________________________________________________

Parents first and Last Names: ______________________________________________________________

Your home phone number w/area code: ______________________________________________________

Your Full home address: __________________________________________________________________

______________________________________________________________________________________

Next of Kin w/phone number and relationship to child(ren):

_____________________________________________________________________________________

Pediatrician phone number with area code:__________________________________________________

_____________________________________________________________________________________

Dentist phone number with area code:______________________________________________________

_____________________________________________________________________________________

Special Instructions:

I authorize _________________________________________________ to make medical decisions for the care of my child(ren) in case we cannot be reached .

__________________________________

__________________________________

Signature Witness

_______________ _________________

Date Date

Insurance Information

Company Name _______________________________________

Policy Number: ________________________________________

Carrier Name & relation to child ____________________________________________

Hospital Choice_________________________________________

Current Medications (include Date)_______________________________