Emergency Medical Authorization

Version 2026.1 · Effective August 23, 2026

Child

• Child’s full name: ______________________________________________
• Date of birth: ____________________
• Known medical conditions or care plans: __________________________

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Parent/guardian contacts

Emergency contacts

Medical information

• Primary healthcare provider and phone: ___________________________
• Preferred hospital or emergency facility: ________________________
• Insurance provider: _____________________________________________
• Policy or member number: _______________________________________
• Allergies or medical alerts: ____________________________________

_______________________________________________________________

Authorization

I authorize Teida’s Tots to seek emergency medical assistance for my child when an emergency occurs and I cannot be reached promptly. I understand that emergency services may be contacted when appropriate and that this authorization does not replace required health-provider orders, medication authorizations, or individual care plans.

I authorize the release of relevant emergency information to emergency responders and healthcare providers as permitted by law.

I understand that Teida’s Tots does not provide routine transportation or field trips. If an emergency requires evacuation or relocation, I authorize emergency-only transportation or transfer to a safe location when necessary to protect my child, legally permitted, and directed by the provider or emergency authorities. The provider will notify me of the confirmed location and reunification instructions as soon as safely possible.

Preferred emergency reunification or relocation information: ______________________________

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☐ I understand and authorize emergency-only relocation or transportation as described above.

• Parent/guardian signature: ______________________________________
• Printed name: _________________________________________________
• Date: ____________________

Annual/update review

• Last reviewed: ____________________
• Parent initials: __________________
• Provider initials: ________________