1. Medical Release/Consent to Treatment
In case of a medical emergency, I,
____________________, hereby give consent to treat my
child, _____________________, to Melissa Finn and
Lady Bug’s Child Care Center.
Signed: _________________________________ Date:
__________________
I release responsibility in case of accidental injury
that occurs while my child is in the care of Lady
Bug’s Child Care. I have listed below our insurance
information and agree to notify Lady Bug’s if
Changes occur with our policy.
Signed: _________________________________ Date:
__________________
Our Insurance information is as follows:
Company:
_______________________________________________________
Policy Holder:
___________________________________________________
Employer:
_______________________________________________________
Policy Number:
_________________________________________________
Family Physician Information:
Doctor: _________________________ Phone:
_________________________

2. Address:
_______________________________________________________
_
Known Allergies:
_______________________________________________
Current
Medications:__________________________________________
__
Date of Last Tetanus
Shot:______________________________________
Special Medical Information:
___________________________________
(THIS IS A LEGAL DOCUMENT. IT MUST BE
NOTARIZED)