Nanny Emergency Consent form

I, …………………………………………..am the custodial parent/guardian of my child/children………………………………………………….

In my absence I have left my child in the care of and do hereby authorise _________________________ (nanny) to consent on my behalf to any medical treatment that my child may require. The following information is given to assist in providing necessary medical care to my child.

Known allergies &type of reaction (medications, foods, environment) __________________________________________________________________________

Current medications: ___________________________________________________

Existing health problems: _______________________________________________

Any vaccination history we need to know about? ___________________________________

Parent’s name printed: ____________________________________

Parents signature:_________________________________________

Date of nanny care: _______________________________________