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Child's Health/Emergency Information and Authorization Form

for Transportation Providers

(To be completed by the child's parent or guardian)

Health/Emergency Information

Child's Name:_________________________________________________________________________________________

Other Name Child Responds to (if applicable

Birthdate:

:_________________________________________

____________________

Parent’ s/Guardian's Name:_______________________________________________________________________________

Address:_____________________________________________________________Home Phone:(

)_______________

Workplace:___________________________________________________________Work Phone:(

)________________

Address where child is to be picked up and returned (if different from above):______________________________________

Person(s) responsible for meeting child being transported:______________________________________________________

In case of emergency and the parent(s)/guardian(s) cannot be reached, please contact one of the following

persons:

Name:______________________________________________________Phone:(

)_____________________

Address:____________________________________________________Relationship:_____________________

Name:______________________________________________________Phone:(

)_____________________

Address:____________________________________________________Relationship:_____________________

Please give specific instructions if your child needs special assistance, equipment, or materials when transported.

____________________________________________________________________________________________________

List any chronic medical condition or allergies your child may have as well as any medications your child may take:

____________________________________________________________________________________________________

Other important information about your child:_______________________________________________________________

____________________________________________________________________________________________________

Authorization for Transportation Services

I authorize the following transportation provider____________________________________________________________to

transport my child to and from the following location _________________________________________________________

Signature of Parent/Guardian____________________________________________________Date_____________________

Authorization for Emergency Medical Care

In case of accident or illness requiring medical attention, the undersigned authorize _______________________

(transportation

provider) to call a health care provider or to take my child________________________________________(child's name) to the nearest

hospital or doctor, and it is understood that if possible, their services will be obtained. If neither parents nor preferred health care provider

can be contacted, the transportation provider is authorized to contact another health care provider. It is also understood that this agreement

covers only those

situations,

which in the best judgment of the transportation provider, are true emergencies.

The health care provider to call is:

My hospital preference is:

Name:____________________________________________ Name:________________________________________

Address:__________________________________________ Address:______________________________________

Phone:(

)______________________________________ Phone:(

)__________________________________

I authorize emergency treatment deemed necessary by a physician in the event that I cannot be reached for permission. I

agree to be responsible for the cost of such emergency medical care.

Signature of Parent/Guardian____________________________________________________Date___________________

DCD-0037

Rev. 3/96

Form Dcd-0037 - Child'S Health/emergency Information And Authorization Form For Transportation Providers

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