Emergency Consent Form
Diana's Lil' Darlings In Home Family Childcare
Where Children Come First
As the parent/legal guardian, I hereby give consent to Diana's Lil' Darlings or it's representatives to provide all emergency dental or medical care prescribed by a duly licensed physician (MD) or (DDS) for my child _______________________. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent. I understand that the cost of this care will be paid for by me.
It is understood that a conscientious effort will be make to notify me before such action is taken if time permits.
In order to meet all legal requirements, I hereby authorize an acting representative of Diana's Lil' Darlings to give consent for any and all necessary emergency medical care for my child.
State of Nevada, County of Clark,
Before me the undersigned authority on this day personally appeared _______________________________
Known by me to be the person whose name is subscribed above, and acknowledged to me that he/she executed the same for the purpose therein expressed.
Sworn and subscribed before me this _____ day of ________, ______
Norary Public
Phone numbers where parent can be reached
Mother Home __________________, Work ____________________, Cell __________________
Father Home __________________, Work ____________________, Cell __________________
Additional person's to be called in case of emergency ____________________________________________________
_____________________________________________________________________________________________
