Babysitter Information Sheet Where I will be: Phone number to reach me: IF YOU CANNOT REACH ME Contact name: Contact phone number: Contact name: Contact phone number: In an emergency call 911 HOME INFORMATION Family Name: Phone: Address: ABOUT THE CHILD(REN) Name: Name: Date of Birth: Date of Birth: Age: Age: Other Information (allergies, medications, etc.): Other Information (allergies, medications, etc.): PEDIATRICIAN CLOSEST HOSPITAL Name: Name: Phone: Phone: Address: Address: INSURANCE INFORMATION Provider: Group number: Name of Insured: Policy number: EMERGENCY TREATMENT RELEASE Child’s Name: Da
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