This form can be completed and signed by the child’s parent or legal guardian. The signature of the parent or legal guardian indicates permission for the babysitter or nanny to follow and act in accordance with these instructions.

(If more than two children you can simply photocopy, complete and attach additional sheets with child’s details)

1.
Name of Child: ____________________________________________
Date of Birth: ____________
Medical Condition(s) of Concern:
___________________________________________________________
___________________________________________________________
___________________________________________________________
Signs and/or Symptom(s) to Watch for:
___________________________________________________________
___________________________________________________________
List the Child’s Medications, Prescription and Over-the-Counter:
Medication: ________________________ Dose: ______________
How Given: ________________________ When Given: ____________
Special Instructions (to be taken with, etc.): ______________________
Possible Side Effects:
__________________________________________________________
__________________________________________________________

2.
Childs name ____________________________________________
Date of Birth: ____________
Medical Condition(s) of Concern:
___________________________________________________________
__________________________________________________________
___________________________________________________________

Signs and/or Symptom(s) to Watch for
___________________________________________________________
___________________________________________________________
Medication: ________________________ Dose: ______________
How Given: ________________________ When Given: ____________
Special Instructions (to be taken with, etc.): ______________________
Possible Side Effects:
___________________________________________________________
___________________________________________________________

I give permission for _______________________________________ (“Babysitter / nanny”) to administer medicine(s) to the child(ren) named above in the manner described above.

Where the babysiiter or nanny is unable to contact me or it is otherwise impracticable to contact me, I authorise to:

-consent to my child(ren) receiving such medical or surgical attention as may be deemed necessary by medical practioner
-administer such first -aid as may judge to be reasonably necessary.
- take the appropriate measures including contacting emergency services and arranging for transportation by ambulance to the nearest hospital to receive the appropriate level of care as determined by qualified medical professionals.

Parent/Legal Guardian’s Name: ___________________________________
Contact Numbers ________________ on ______________ (hours/days)
________________ on ______________ (hours/days)
________________ on ______________ (hours/days)

Parent/Legal Guardian Signature Date
___________________________________    Date______________


Note: Babysitterdirectory recommends that all carers caring for children should have appropriate nanny insurance. Find out more here.


Disclaimer
Babysitterdirectory has published the information above in good faith and is based on information that we knew at the time of publishing. Please understand that we are not professional legal advisers and that we provide general information without considering your particular circumstances.  We have researched and summarised the information and made general statements, you must decide at your own risk whether what we say is applicable to you and relates to your specific situation. This information is not intended to substitute for professional advice and neither is it meant to be exhaustive. Babysitterdirectory does not  warrant or represent that the information is free from errors or omission,or that it is exhaustive. We recommend that you recheck all information with a professional advisor to ensure it applies to your specific situation.

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