Instructions: Please complete one card for each child. The Medical Treatment Consent portion authorizes emergency treatment at any hospital, making this card valid wherever your child may be staying. The medical information portions will save valuable time if treatment needs to be provided. Please complete all blanks, sign, and give this card to the person caring for your child, with instructions to give it to the hospital/physician if treatment is needed.

Child's Name

Birthdate
(day/month/year)

Physician's
Name

Medications child is taking now:
Allergies Last Tetanus vaccination
Other special information:
Child's health insurance cd. & policy no:
Parents may be reach at (address / telephone number):
If parents unavailable contact: Name Address