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AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT
Full Legal Name:
Alternate contact in the
cannot be reached:
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.
Signed this ______day of____________________, 20 ____.
STATE OF __________________
This document was acknowledged before me on ______________________ [date] by ________________________________________________ [name of principal].
[Notary Seal, if any]:
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