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The following is an example of information that all parents should leave with ALL babysitters (including grandparents). You can hit the PDF button to the right of the title and print this version or create your own version, but make sure this information is in the hands of anyone caring for your child!
Caregivers Checklist
Our home address:
__________________________________________________________
Our home phone number:
_________________________
Where I can be reached:
Location: _______________________________ Phone Number:___________________
Our cellular phone numbers: ________________________ ______________________
I expect to be home at this time:__________________________
Who to call if you can�t reach me:
Name: __________________________________ Phone Number: _________________
Name: __________________________________ Phone Number: _________________
Out of Area Contact:
Name: __________________________________ Phone Number: _________________
What child can eat and when: ______________________________________________________________________
What [child] cannot eat:
______________________________________________________________________
What [child] can watch on TV (favorite shows and channels):
______________________________________________________________________
What [child] cannot watch on TV:
______________________________________________________________________
Things [child] likes to do (favorite activities such as art projects, books,games etc) :
______________________________________________________________________
Things not allowed:
______________________________________________________________________
Bedtime (time and routine):
______________________________________________________________________
Common discipline problems:
______________________________________________________________________
Consequences for misbehavior:
______________________________________________________________________
In Case of Emergency:
Our closest major intersection is:
______________________________________________________________________
Our closest neighbor you can contact in an emergency:
Name:______________________________ Phone number: _____________________
Address: ______________________________________________________________________
In case of evacuation, meet at this place:
______________________________________________________________________
Pediatrician's Name, Address, and Phone Number
______________________________________________________________________
Closest Hospital and Directions
______________________________________________________________________ ______________________________________________________________________
Hospital ER Phone Number: __________________________
Insurance Information
Provider: _______________________ Group ID# _______________________
Insured�s Name and ID# __________________________ Policy ID# ______________
Emergency Treatment Release
Child's Name: _____________________________ Birthdate: / /
Any licensed physician, dentist or hospital may give necessary emergency medical service to my child/ren _____________________________________________________ at the request of the person bearing this consent form.
____________________________________________ _________________
Signature of Parent or Legal Guardian Dates of Release
All caregivers must have a copy of their current drivers license with this form.
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Communication 
