Single MOMM consent for medical and/or emergency treatment and liability waiver for revive childcare

I, *
I,
(Relationship of child to you)
(Full Name of child, hereafter "dependent")
I further give my consent to Single MOMM who will be caring for my dependent for 2016 to arrange for routine or emergency medical and/or dental care and treatment necessary to preserve the health of my dependent. In the event that my dependent is injured or ill while under the care of the caregiver, I hereby give permission to the caregiver to provide first aid for said dependent and to take the appropriate measures, including contacting the Emergency Medical Service (EMS) system and arranging for transportation to the nearest emergency medical facility. In making medical decisions on my behalf for the benefit of my dependent, I direct that the caregiver attempt to contact me. However, if medical care becomes essential, I give permission to the caregiver to make such decisions regarding such treatment as deemed appropriate by the medical doctor, hospital or their authorized designee. In furtherance of any treatment decisions to be made by the caregiver on my behalf for the benefit of my dependent, I authorize the caregiver to request, obtain, review and inspect any and all information bearing upon my dependent’s health and relevant to any such decisions to be made respecting such treatment. I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on the condition of my dependent and that I am responsible for all reasonable charges in connection with the care and treatment rendered to my dependent during this period. I agree to hold Single MOMM and any associated agencies and persons free and waive any claims for payment of accident, injury, disability and damages to the person or property of the aforementioned child. I undersigned assume(s) all risk of injury or harm to the child associated with participation in reVIVE childcare and agree(s) to release, indemnify, defend and forever discharge Single MOMM and its staff, employees, volunteers and agents of and from all liability, claims, demands, damages, costs, expenses, actions and causes of action in respect of death, injury, loss or damage to the child, or by the child, howsoever caused, arising or to arise by reason of or during the child’s participation in reVIVE child care. *
I further give my consent to Single MOMM who will be caring for my dependent for 2016 to arrange for routine or emergency medical and/or dental care and treatment necessary to preserve the health of my dependent. In the event that my dependent is injured or ill while under the care of the caregiver, I hereby give permission to the caregiver to provide first aid for said dependent and to take the appropriate measures, including contacting the Emergency Medical Service (EMS) system and arranging for transportation to the nearest emergency medical facility. In making medical decisions on my behalf for the benefit of my dependent, I direct that the caregiver attempt to contact me. However, if medical care becomes essential, I give permission to the caregiver to make such decisions regarding such treatment as deemed appropriate by the medical doctor, hospital or their authorized designee. In furtherance of any treatment decisions to be made by the caregiver on my behalf for the benefit of my dependent, I authorize the caregiver to request, obtain, review and inspect any and all information bearing upon my dependent’s health and relevant to any such decisions to be made respecting such treatment. I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on the condition of my dependent and that I am responsible for all reasonable charges in connection with the care and treatment rendered to my dependent during this period. I agree to hold Single MOMM and any associated agencies and persons free and waive any claims for payment of accident, injury, disability and damages to the person or property of the aforementioned child. I undersigned assume(s) all risk of injury or harm to the child associated with participation in reVIVE childcare and agree(s) to release, indemnify, defend and forever discharge Single MOMM and its staff, employees, volunteers and agents of and from all liability, claims, demands, damages, costs, expenses, actions and causes of action in respect of death, injury, loss or damage to the child, or by the child, howsoever caused, arising or to arise by reason of or during the child’s participation in reVIVE child care.
Name of Legal Guardian
Name of Dependent *
Name of Dependent
Today's Date *
Today's Date
Address *
Address
Phone *
Phone
Physician Name *
Physician Name
Physician Phone Number *
Physician Phone Number
Dentist Phone *
Dentist Phone
Date of Dependent's last tetanus shot *
Date of Dependent's last tetanus shot
Emergency Contact Person
Emergency Contact Person
Emergency Contact Phone Number
Emergency Contact Phone Number

Updated 2/1/16 Consent for Medical and/or Emergency Treatment and Liability waiver for reVIVE childcare.