Babysitter Consent and Contact Form

This is from the American Red Cross Infant CPR portion of the 2001 Red Cross First Aid/CPR/AED program. The text says: “This page may be duplicated by individuals and contacts for noncommercial purposes.”

It’s for parents to fill out and leave with the babysitter or designated caregiver ( including relatives who might not be fully aware of current health issues for your child).

You might want to add information about the child’s allergies (which food, medications, insects), medications (prescription, over-the-counter, herbal), medical conditions (Diabetic? Epilepsy? Asthma?), date of last Tetanus shot, blood type and any recent health problems, surgeries or injuries.

You could also specify an alternate contact or two (write out the name/phone number) if you can’t be reached, including pointing out which nearby house has a family you trust that knows you will be out.

Where are the prescriptions / over-the-counter medications (and what are the instructions for their use) that you would trust this babysitter to give your child?

Point out the child’s Medic Alert tag to the babysitter.

Is there a list of important phone numbers next to the phone… vet, family doctor, poison control, trusted neighbor…?

Have you made an emergency plan for exiting the house if needed, do you practice it, and where is everyone supposed to meet outside? Scroll down to Evacuations at Disaster Planning

Perhaps go over important points with the babysitter using these Red Cross babysitting textbooks:

Consent and Contact Form

This form is to be completed and signed by the child’s parent or legal guardian.

Name of child:___________________________________________

In the event the child named above is injured or ill, I understand that the caregiver will attempt to contact me, the other parent, or the legal guardian at the telephone number provided below.

Parent’s (legal guardian’s name:______________________

Telephone numbers __________________on ______________(hours/days)

___________________on ___________________(hours/days)

Parent’s (legal guardian’s) name: _______________________

Telephone numbers __________________on ______________(hours/days)

___________________on ___________________(hours/days)

In the event that I or the others listed are not available, I give my permission to the caregiver to provide first aid for the child named above and to take the appropriate measures including contacting the emergency medical services (EMS) system and arranging for transportation to ________________________________________

or the nearest emergency medical facility. At no time will the caregiver drive an ill or injured child to an emergency medical facility unless accompanied by another adult.

Signature ___________________________ Date _______________


Teach your children their basic personal information in case they become separated from care givers.

Regularly update your child’s school with current health status info, emergency contact info and info (perhaps with a photo) as to who is authorized to pick them up

Make sure each child (especially those of cell phone use age) knows how to contact your out-of-state contact person (if you don’t understand this concept see: Disaster planning )

see also:

Helping Children Cope With Disaster


The author of this webpage, (written as a homework reading assignment for my students), does not give any warranty, expressed or implied, nor assume any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, product, or process included in this website or at websites linked to or from it. Users of information from this website assume all liability arising from such use.