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http://faculty.deanza.edu/donahuemary/BabysitterConsentandContactForm

Babysitter Consent and Contact Form

This is from the American Red Cross Infant CPR portion of the 2001 Red Cross First

Aid/CPR/AED program. The text says: "This page may be duplicated by individuals and

contacts for noncommercial purposes."

It's for parents to fill out and leave with the babysitter or designated caregiver. You might want

to add information about the child's allergies ( which food, medications, insects), medications

(prescription, over-the-counter, herbal), medical conditions (Diabetic? Epilepsy? Asthma?), date

of last Tetanus shot, blood type and any recent health problems, surgeries or injuries. You could

also specify an alternate contact or two if you can't be reached.

Point out the child's Medic Alert tag to the babysitter.

Is there a list of important phone numbers next to the phone... vet, family doctor, poison control,

trusted neighbor...?

Consent and Contact Form

This form is to be completed and signed by the child's parent or legal guardian.

Name of child:___________________________________________

In the event the child named above is injured or ill, I understand that the caregiver will attempt tocontact me, the other parent, or the legal guardian at the telephone number provided below.

Parent's (legal guardian's name:______________________

Telephone numbers __________________on ______________(hours/days)

___________________on ___________________(hours/days)

Parent's (legal guardian's) name: _______________________

Telephone numbers __________________on ______________(hours/days)

___________________on ___________________(hours/days)

In the event that I or the others listed are not available, I give my permission to the caregiver to

provide first aid for the child named above and to take the appropriate measures including

contacting the emergency medical services (EMS) system and arranging for transportation to

________________________________________

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or the nearest emergency medical facility. At no time will the caregiver drive an ill or injured

child to an emergency medical facility unless accompanied by another adult.

Signature ___________________________ Date _______________

_________________________________________________

Teach your children their basic personal information in case they become separated from care

givers.

Regularly update your child's school with current health status info, emergency contact info and

info as to who is authorised to pick them up

Make sure each child (especially those of cell phone use age) knows how to contact your out-of-

state contact person (if you don't understand this concept see:Disaster planning)

http://faculty.deanza.edu/donahuemary/Disasterplanninghttp://faculty.deanza.edu/donahuemary/Disasterplanninghttp://faculty.deanza.edu/donahuemary/Disasterplanninghttp://faculty.deanza.edu/donahuemary/Disasterplanning