Babysitter Medical Release Form

Authorize a caregiver to seek emergency medical treatment for your child by recording doctor, insurance, and signature details in one document.

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Valid From

Valid To

Child's Name

First Name

Last Name

Child's Date of Birth

Gender

Child's Doctor

First Name

Last Name

Doctor's Phone Number

Hospital

Child's Allergies and Medical Conditions

Child's Health Insurance Provider

Policy Number

Parent/Guardian Name

First Name

Last Name

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Babysitter Name

First Name

Last Name

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Special Instructions or Additional Authorization

Parent/Guardian Signature

Sign here

Babysitter Signature

Sign here

Date

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