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In Case of Emergency Imagination Time LLC

This document outlines emergency procedures and authorizations for a child care provider. It authorizes the provider to obtain emergency medical care, transportation, and administer CPR if needed for the child. The parent is responsible for any medical bills. In a disaster, the child will remain on the premises until an authorized individual can pick them up. It requests emergency contact information and preferences for hospitals and physicians. The provider can only administer prescribed medications that are properly labeled and nonprescription medication provided by the parent with authorization.

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Missy Monsivais
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© Attribution Non-Commercial (BY-NC)
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241 views

In Case of Emergency Imagination Time LLC

This document outlines emergency procedures and authorizations for a child care provider. It authorizes the provider to obtain emergency medical care, transportation, and administer CPR if needed for the child. The parent is responsible for any medical bills. In a disaster, the child will remain on the premises until an authorized individual can pick them up. It requests emergency contact information and preferences for hospitals and physicians. The provider can only administer prescribed medications that are properly labeled and nonprescription medication provided by the parent with authorization.

Uploaded by

Missy Monsivais
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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In Case of Emergency

Imagination Time LLC


Missy Monsivais
322 North 3335 West
West Point, Utah 84015
(801)-775-0369
Please initial all lines

_____ I understand that my child care provider can only give medication that is accompanied by a
medical release form. My provider has the required form available for me if needed.

_____ In case of an emergency or serious illness, I hereby authorize the caregiver to obtain emergency
medical care; i.e. physician, dentist, paramedics, or other emergency agents. She is also authorized to
obtain or provide emergency medical transportation. If needed, I authorize the administration of CPR.

_____ I understand and agree that I am responsible for any bills as a result of a medical emergency.

_____ In case of a disaster, I understand that my child will be kept on the premises until they are picked
up by an authorized individual. This is as long as the home is safe and there have been no additional
directions given by the State of Utah.

If there is an emergency, I prefer that my child care provider obtain emergency services from

__________________________ Hospital. I also prefer that my child’s primary care physician is used.

His/Her name is _________________________ and he/she works at ____________________________.

Their Phone number is ________________________.

Primary emergency contact to call in case of illness/emergency and parent/guardian cannot be reached:

Name____________________________________________Relation____________________________

Telephone Numbers______________________________ ____________________________________

The child care provider can only give prescribed medication if the correct date is on the bottle.
The bottle must also have the name of the child whom it is being administered to, the correct
procedures for administering the medication, and the physicians name and number marked
clearly on the bottle. By signing below the parent/guardian is giving the child care provider
permission to provide nonprescription mediation such as Tylenol that has been provided by the
parent/guardian.
Signature of Parent/Guardian__________________________________________

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