AUTHORIZATION FOR MINOR'S
MEDICAL TREATMENT
Child
Full Legal Name:
___________________________________________________________________
Date of Birth:
_______________________ Age: ___________ Gender:
___________
Doctor’s Information
Doctor’s Name:
____________________________________________________________________
Doctor’s Address:
__________________________________________________________________
Doctor’s Office Phone: ____________________ Doctor’s Emergency Phone:
__________________
Medical Insurer/Health Plan: __________________________ Policy #: ______________________
Allergies to Medications:
_____________________________________________________________
Allergies (Other):
___________________________________________________________________
If applicable, please note the
conditions for which the child is currently receiving treatment:
_________________________________________________________________________________
Note any other significant
medical information:
_________________________________________________________________________________
_________________________________________________________________________________
Dentist’s Information
Dentist’s Name:
____________________________________________________________________
Dentist’s Address:
__________________________________________________________________
Dentist’s Office Phone: ____________________ Dentist’s Emergency Phone:
__________________
Dentist’s Insurer/Health Plan:
__________________________ Policy #:
_____________________
Parent(s)/Legal Guardian(s):
Parent #1:
Name:
___________________________________________________________________________
Address:
________________________________________________________________________
Home phone: __________________________ Work
phone: ____________________________
Cell phone: ____________________________ Pager:
_________________________________
Email: ________________________________
Additional Contact Information:
_______________________________________________________
_________________________________________________________________________________
Parent #2:
Name:
___________________________________________________________________________
Address:
________________________________________________________________________
Home phone: __________________________ Work
phone: ____________________________
Cell phone: ____________________________ Pager:
_________________________________
Email: ________________________________
Additional Contact Information:
_______________________________________________________
_________________________________________________________________________________
Alternate contact in the
event
Parent(s)/Legal Guardian(s)
cannot be reached:
Name:
___________________________________________________________________________
Address:
________________________________________________________________________
Home phone: __________________________ Work
phone: ____________________________
Cell phone: ____________________________ Pager:
_________________________________
Email: ________________________________
Additional Contact Information:
_______________________________________________________
_________________________________________________________________________________
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.
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 Notarial Officer)
Notary Public for the State of ______________
My commission expires: __________________
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