Please fill in all blanks or write N/A
Parent or Guardian's Home Address and Employment Address
Person(s) to Whom the Child(ren) may be Released by the Caregiver: ALL FIELDS MUST BE FILLED OUT PER STATE REGULATIONS (If no one, please write "none")
Person(s) Who Will Take Responsibility for the Child(ren) in an Emergency When the Parent (or Guardian) Cannot be reached:
(ONE NAME MUST BE GIVEN)
Consent to Contact Physician in Emergency
MEDICATION COMPETENCY STATEMENT
is/are competent to give or apply medication to my child(ren)."
I certify that the above information is correct to the best of my knowledge.