Babysitter Consent and Contact FormThis 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, medications (prescription, over-the-counter, herbal), medical conditions (Diabetic? Epilepsy? Asthma?)and any recent health problems or injuries.
Point out the child's Medic Alert tag to the babysitter.
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 to
contact 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 ________________________________________
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 _______________
_________________________________________________
see also:
Helping Children Cope With Disaster
Disaster planning
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