Caring Hands Agency
Child Care Authorization

* only to be used for sits as needed - not part of original registration packet.
Please print this form and complete per instructions at page bottom.

The undersigned parent(s) or guardian:

Name _____________________________________________________________

Home Phone _______________________________________________________

Address ___________________________________________________________

City, State, Zip _____________________________________________________

Work Phone _______________________________________________________

hereby grants(s) ____________________________, the authority to take temporary care of the following child(ren):

Name__________________________________  Age _________________

Name__________________________________  Age _________________

Name__________________________________  Age _________________

Name__________________________________  Age _________________

This grant of temporary authority shall begin on (date) ________________ and shall remain effective through (date) ___________________.

The above named caretaker(s) shall have the following powers:

  • The power to seek appropriate medical treatment or attention on behalf of the child(ren) as may be required by the circumstances, including but not limited to, medical doctor and/or hospital visits.
  • The power to authorize medical treatment or medical procedures in an emergency situation.
  • Your signature below indicates your agreement that the child(ren) named above has permission to participate in special activities which may or may not include transportation to another location in the above named caregiver's personal vehicle during the period covered by this form.
  • Your signature below indicates your agreement that the child(ren) named above has permission to participate in swimming activities during the period covered by this form.

 

Signature of parent/guardian _________________________________  Date ___________

SPECIAL INSTRUCTIONS: please write instruction in space below.

 

 

 

 

 

Instructions for submitting this form

  1. Fax (only if 1st date of service requested is less than 7 days from today's date.) to 214-520-1882. 

  2. Be sure to include copy of your registration payment. (Mail original pages and check to: Caring Hands Agency, P.O. Box 7411 Dallas, TX 75209-7411

  3. Mail all other registrations (1st use of service more than 7 days from today's date, do not fax). 

  4. You will receive a welcome packet upon receipt of your mailed registration payment.

  5. Call us at 214-520-1191 with any questions.  Thank You!