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Temporary Authorization Form – UA

Temporary Authorization Form
This temporary authorization form, hereby grants the caregiver(s) listed below, the following permissions. This authorization form will override the Care Permissions Form we have on file for the date(s) indicated.
I permit the caregiver(s) listed below to administer medication.
- Yes
- No
Medication Type:
Dosage/Time(s) to Administer
I permit the caregiver(s) listed below to supervise swimming play.
- Yes
- No
Special Instructions:
I permit the caregiver(s) listed below to walk my child(ren) to/from school or the bus stop.
- Yes
- No
Special Instructions:
Name of Caregiver(s)*
Date(s) Valid*
Parent/Guardian Name*
Signature*
Date Signed*
MM slash DD slash YYYY
Client Email

Please enter your email address if you would like to receive a copy of your submission.
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Locations

Phoenix

7135 E Camelback Rd. Suite 230
Scottsdale, AZ, US 85251

480.745.5762

Tucson

4425 N. Campbell Avenue
Tucson, Arizona 85718

520.544.6612

Dallas-Fort Worth

1560 E. Southlake Boulevard, Suite 100
Southlake, TX 76092

817.993.6288

Trusting Connections Nanny Agency is an award-winning nanny placement agency and sitter service.

We connect families and organizations with exceptional nannies, sitters, and other childcare professionals.

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Headquarters

520.544.6612

info@trustingconnections.com

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