Mom’s Full Name:
Dad’s Full Name:
If you can’t reach Mom or Dad, please call:
Child’s Full Name:
Phone Number (including after hours number):
*If you will be going on an overnight trip, make sure pediatrician has a note/permission for whoever is caring for baby to bring them into the pediatrician’s office if needed.
In case of an emergency, call 911.
Our Home Address:
By signing this form, I authorize Caregiver to call 911 on behalf of my child in case of an emergency:
This form expires on:
*Always go over safe sleep practices with the caregiver.*
Safe Sleep: Always put baby on their back to sleep, nothing else in the crib. No loveys, no stuffed animals, no blankets, no toys, no mobiles. Never fall asleep while holding baby.
Tips, Tricks and Other Things You Should Know:
Sheet for Babysitter to Fill Out
Please write below the times you fed the baby and how much they ate in the bottle:
How bedtime went:
Anything else I should know: