Fill and Sign the Medical Treatment Authorization Form

Medical Treatment Authorization for Child Care Provider To Whom It May Concern: 1. ____________________________ (Name of Child Care Provider) , hereafter referred to as child care provider is the child care provider for our child, __________________________ (Name of Child) . Child care provider is responsible for his/her care and welfare during the day, and occasionally in the evenings, on the weekends or overnight. 2. We hereby authorize and voluntarily consent to having child care provider arrange, direct, sign for and consent to any and all routine or emergency medical care and treatment necessary to preserve the health of our child. Personal, insurance and health care provider information is set forth below. 3. We acknowledge that we are responsible for all reasonable charges in connection with the care and treatment rendered and acknowledge that no guarantees have been made as to the effect of such treatment rendered. Child Personal Information Name: _____________________________________________________________ Date of Birth: _________________________ Sex: __________________ Color of Eyes: ________________ Color of Hair: ________________ Allergies: _______________________________________________________________ Medical Conditions:________________________________________________________ ________________________________________________________ Social Security #: __________________________________________________________ Insurance Information:  Employer: _________________________________________________________  Member No.: _______________________________________  Employee Social Security No.: _________________  Administrator: _________________________________________________________  Group No.: ____________________________  Confirmation Number: _________________________________________________ Health Care Providers:  Pediatrician: Name: _________________________________________________  Phone Number: __________________________________ Dentist: Name: _________________________________________________  Phone Number: _________________________________________________ Witness our signatures this ____________________ (date) . ____________________________ ___________________________ Printed Name of Parent Printed Name of Parent ____________________________ ___________________________ Signature of parent Signature of Parent (Acknowledgment form may vary by state) STATE OF ______________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for the said county and state, on this _____ day of ______________, 20_____, within my jurisdiction, the within named, _______________________________________________ (Names of each Parent) , who acknowledged that they executed the above and fore going instrument. _____________________ NOTARY PUBLIC My Commission expires: ______________________