authorize for emergency medical attention

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

I give consent for the facility to secure any and all necessary emergency medical care for my child.



Work to for School and home,

I have provided the childcare operation with a copy of my child's most current immunization record.

If  Your Child does not attend pre-kindergarten or school away from   the child -care operation, one  of the following must be presented when your child to the child-care operation or withinn one week of admission.

HEALTH TH-CARE PROFESSIONAL'S STATEMENT: I have examined the above-named child within the past year and find that he/she is able to take part in the  care in the day care program.

A signed  and deleted copy of  a health care professional's statement is attached.

Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of I have attached a signed and dated  affidavit stating this.

My Child has been examined  within the past year by a health care professional and  is able to participate in the day care program.within 12 months of admission.i will obtain a health care professional's signed statement and I will submit it to the child-care  operation




Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease.  If your child has had chickenpox, please complete the

I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief.  I have attached an official notarized affidavit form developed and issued by the Department of State Health Services.  I understand this affidavit is valid for 2 years.