Medical Treatment Authorization and Consent

I, ____________________[Full Legal Name of Parent/Guardian], being the [parent/legal guardian] of ____________________[Child’s Full Name] authorize ____________________[Full Name of Caregiver] to seek, obtain and consent to [routine medical care and treatment/emergency medical care and treatment/ surgery/hospitalization/blood transfusions/dental care and treatment/other] for ____________________[Child’s Full Name] as deemed necessary by a licensed medical or healthcare professional. This authorization is for the time period when my child is in the care of ____________________[Full Name of Caregiver], my child’s ____________________[Relationship to Child (e.g. grandmother, grandfather, aunt, uncle, nanny, baby-sitter, family friend, teacher)] and is effective _________ until __________.

Child’s Information

Child’s Full Name: ______________________________________________________________ Address:______________________________________________________________________Date of Birth: ______________________________ Age: _______________________________

Parent/Guardian’s Information

Parent’s/Guardian’s Name 1: ______________________________________________________ Address: ______________________________________________________________________ Phone Number (H): _________________________ Phone Number (C): ___________________

Parent’s/Guardian’s Name 2: ______________________________________________________ Address: ______________________________________________________________________ Phone Number (H): _________________________ Phone Number (C): ___________________

Child’s Health Information

Health Conditions (e.g. Asthma, Diabetes): __________________________________________ Allergies (e.g. to Medications, Food): _______________________________________________ Prescription Medications: ________________________________________________________ Date of Last Tetanus Injection/Booster: _____________________________________________

Child’s Medical Care and Insurance Information

Physician/Pediatrician: ______________________ Phone Number: ______________________ Dentist/Orthodontist: _______________________ Phone Number: ______________________ Preferred Medical Facility: _______________________________________________________ Insurance Company: ____________________________________________________________ Policy/Group Number: _______________________Policy Holder: _______________________

SIGNATURE OF PARENT/GUARDIAN

Signature ____________________________ Date _______________________________ Print Name _______________________________

WITNESS

Witness Signature ___________________________ Date _______________________________ Print Name _______________________________ Address ____________

NOTARY ACKNOWLEDGMENT

State of _______________ County of _____________

On this ___ day of _______________ in the year 20___ before me, _______, appeared _______, who is personally known to me or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it.

Notary Seal

_______________________ (Signature of Notary Public)

My Commission Expires: _______________