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.

Use this template

Valid From

Valid To

Child's Name

Nombre

Apellido

Child's Date of Birth

Gender

Child's Doctor

Nombre

Apellido

Doctor's Phone Number

Hospital

Child's Allergies and Medical Conditions

Child's Health Insurance Provider

Policy Number

Parent/Guardian Name

Nombre

Apellido

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Babysitter Name

Nombre

Apellido

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Special Instructions or Additional Authorization

Parent/Guardian Signature

Sign here

Babysitter Signature

Sign here

Date

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