(Thank you Kelly for sharing this form!)
AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT
Children:
Full Legal Name:
Date of Birth:
Full Legal Name:
Date of Birth:
Health Information:
Doctor’s Name:
Doctor’s Address:
Doctor’s Office Phone:
Doctor’s Emergency Phone:
Medical Insurer/Health Plan:
Policy #
Allergies to Medications: None Known
Allergies (Other): None Known
Note any other significant medical information:
_____________________________________________________________________________
_____________________________________________________________________________
Parent(s)/Legal Guardian(s):
Name:
Address:
Cell phone:
Work phone:
Email:
Alternate Contact (Maternal Grandparents):
Name:
Home phone:
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
I do hereby solemnly swear that I have legal custody of the aforementioned minor child(ren).
I grant my authorization and consent for _____________________________________________ (hereafter “Supervising Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.
It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.
This authorization is effective commencing on the ______day of ____________________, 20_____ and expiring on the ______day of ____________________, 20____.
Signed this ______day of____________________, 20 ____.
______________________________________
Parent #1’s Signature
______________________________________
Parent #2’s Signature
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
STATE OF __________________
COUNTY OF ________________
This document was acknowledged before me on ______________________ [date] by ________________________________________________ [name of principal].
[Notary Seal, if any]:
_______________________________
(Signature of Notary Officer)
Notary Public for the State of ______________
My commission expires: __________________
