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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 MGH Backup Child Care Center to transport my child to Massachusetts General Hospital or ____________________________ (name of hospital preferred) and to secure for my child the necessary medical treatment including anesthesia. I understand the teachers in the MGH Backup Child Care Cetner 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 MGH MEDICAL NUMBER: (if applicable) __________________________________

PARENT/GUARDIAN SIGNATURE:________________________________
                         PRINT FULL NAME:________________________________
                                                 DATE:________________________________