• A. Complete the following:

  • B. List two people who can be contacted in an emergency if the parent cannot be reached:

  • C. Complete the following:

  • D. Either Part I or Part II must be completed. Do not complete both

    This form only authorizes the child care facility to secure emergency transportation for a child. This form does not authorize or guarantee treatment upon arrival at the designated source of emergency medical or dental treatment, as each emergency facility set their own treatment procedures.
  • Part I. Permission to Transport Child
  • (name of facility)
  • (name of child)
  • (hospital or clinic)
  • (dentist or dental clinic)
  • for emergency dental care, or to the nearest available source of assistance.
  • Part II. Refusal to Grant Permission
  • (name of facility)

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