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| BWH BACKUP CHILD CARE
CENTER - 850 Boylston Street EMERGENCY AUTHORIZATION AND CONSENT FORM |
NAME OF CHILD:________________________________________________________________
I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child.
However, if I cannot be reached, I hereby authorize the BWH Backup Child Care Center to transport my child to Brigham and Women's Hospital or _________________________________________ (name of hospital preferred) and to secure for my child the necessary medical treatment including anesthesia. I understand the Teachers in the BWH Backup Child Care Center are trained in the basics of First Aid and I authorize them to give my child First Aid when appropriate.
Is your child allergic to any medications? If so please state:
Allergy: _____________________________________ Reaction: __________________________
PARENT/GUARDIAN SIGNATURE:__________________________________________________
DATE:__________________________________________________
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MEDICAL INSURANCE WITH:______________________________________________________
POLICY NUMBER:_______________________________________________________________
DOCTOR'S NAME:_______________________________________________________________
DOCTOR'S ADDRESS:____________________________________________________________
DOCTOR'S PHONE:______________________________________________________________
CHILD'S BWH MEDICAL NUMBER: (if applicable) _______________________________
PARENT/GUARDIAN SIGNATURE:___________________________________________
PRINT
FULL NAME:___________________________________________
DATE:___________________________________________