Daycare Emergency Medical Release Form

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Emergency Medical Release Form

This form authorizes

_______________________________________________________ of

(provider's name)

_______________________________________________________

(daycare name)

to secure EMERGENCY medical care for

_______________________________________________________

(child's name)

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.

_______________________________________________________

(Doctor/Hospital/Clinic Name)

preferred for treatment.

Mother's Signature: ___________________ Date: _________________

Father's Signature: ____________________ Date: _________________