Fillable Child Profile Form (Page 4 of 4) in pdf

Name of child: ___________________________________ Date: ________________________________

PARENTAL CONSENT FOR EMERGENCY CARE AND TRANSPORTATION

If at any time, due to circumstances such as an injury or sudden illness, medical treatment is necessary, I (we)

authorize the operator/administrator/staff of ____________________________________, to take whatever

emergency measures are necessary for the protection of (our) my child while in their care.

I understand this may involve applying first aid, calling a physician or nurse, carrying out the instructions given,

and/or transporting my (our) child to a hospital, including the possible use of an emergency vehicle.

I understand that this may be necessary prior to contacting me (us) and that any expenses incurred for such

treatment, including emergency transportation is my (our) responsibility.

ADMINISTRATION OF MEDICATION RECORD – Acetaminophen

This authorizes staff of ________________________________ to administer acetaminophen to

(Name of child)____________________ providing the procedures outlined below have been taken.

At the first appearance of symptoms (i.e. Fever), proceed as follows: (To be completed by the parent)

____________________________________________________________________________________

1. Take and record the child’s temperature and symptoms on the Potential Illness form.

2. Contact the parents to discuss the symptoms and the child’s temperature and to receive the parent’s

oral consent for administering acetaminophen. Be sure to have the parent confirm with you the dosage

to be administered.

3. Administer the medication in accordance with the parent’s directions and record on the Administration

of Medication form.

4. Ensure that the parent signs the appropriate space on the Administration of Medication form upon

their arrival at the day care centre to confirm that he/she was consulted and is in agreement with the

dosage given.

CONSENT FOR OUTINGS, EXCURSIONS, ACTIVITIES OFF THE PREMISES OF THE DAY CARE FACILITY

I ________________________ the parent/guardian(s) of ______________________________________

authorize the operator/ administrator/ staff of _______________________________ to take my (our) child on

outings, excursions and activities away from the facility, either on foot or in a vehicle providing the driver and

said vehicle are properly insured for the carrying of passengers.

I (we) understand that I (we) will receive advance notice of each planned outing, excursion, or activity away

from the premises.

Parent signature ___________________________________

Date _____________________________

Parent signature ___________________________________

Date _____________________________

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Child Profile Form Page 4