Form Cred-0364 - Children'S Record Page 2
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2Consent to Contact Physician in Emergency:
In the event I cannot be reached to make arrangements, I hereby give my consent to _________________________________
Caregiver
to contact Doctor _________________________________
_______________________________________________
Name of Physician
Phone
_______________________________________________________________ and, if necessary, take my child(ren) to the
Address
City
following doctor(s), clinics, or hospital ______________________________________________________________________
_______________________________________________________
____________________
Signature of Parent/Guardian
Date
MEDICATION COMPETENCY STATEMENT
I,_______________________________________________________________________________________have determined
Parent /Guardian Name
that__________________________________________________is/are competent to give or apply medication to my child(ren).
Provider/Director/Staff Name(s)
______________________________________________________________
_________________________
Signature of Parent/Guardian
Date
CHILD'S MEDICAL INFORMATION
Current health status or any health problems caregiver should know: ____________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Medication, if any: ____________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
List any allergies and/or intolerance to food, insect bites, or stings, or other factors that result in a medical reaction. Please
give clear instructions in the event of an exposure of the factor: _________________________________________________
Special Concerns: (Glasses, Hearing Aid, Crutches)__________________________________________________________
Any activities child(ren) should NOT engage in: _____________________________________________________________
Company providing health and/or accident insurance coverage: (Optional) ________________________________________
I certify that the above information is correct to the best of my knowledge.
_____________________________________________________________ _____________________________________
Signature of Parent/Guardian
Date
CRED-0364 Page 2
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