Emergency Care Authorization

Child's Full Name
First Middle Last
Date of Birth
MM slash DD slash YYYY
Date of Last Tetanus Shot
MM slash DD slash YYYY
Child is allergic to the following medications:
- None
Child is taking the following medications:
- None
Child is diabetic, has other chronic condition or major illness:
- None
Name of primary care physician:
Primary care physician phone number:
For your child’s comfort and safety, please indicate any special conditions we may need to know about (allergies, medical prescriptions, recent injuries or illnesses, etc.; use additional paper if necessary):
Parent/Guardian Name:
First Last
Parent/Guardian Cell Phone
Parent/Guardian Home Phone
Parent/Guardian Work Phone
Parent/Guardian Other Phone
Emergency Contact if Parent/Guardian cannot be reached:
First Last
Relationship to child
Emergency Contact Phone
I, the undersigned give permission for caring for the above named child to Castle Rock Ranch LLC. I hereby authorize the Castle Rock Ranch LLC to sign for medical treatment of my child(ren) between the following dates:
From
MM slash DD slash YYYY
Until
MM slash DD slash YYYY
Signature*
Date Signed
MM slash DD slash YYYY
Witnessed by
First Last
Witness Phone
Witness Address