AUTHORIZATION FOR MEDICAL TREATMENT OF

Child's Name

We are the parents of Child's Name (born on Date of Birth).

We hereby grant our authorization and consent for Adult 1 and/or Adult 2 (“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, we 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.

We also authorize Supervising Adult to utilize our current health insurance plan for the care of Child's Name. This letter shall be in effect, unless revoked in writing, from Beginning Effective Date to Ending Effective Date.

Sign Above and Type Parent Name Here

City, County Name County, State

Sign Above and Type Parent Name Here

City, County Name County, State

NOTARIZATION

STATE OF STATE

COUNTY OF COUNTY

Before me personally appeared Parent Name and Parent Name, individuals who are known to me, and who, being sworn, acknowledged the execution of the foregoing Authorization for Medical Treatment of a Minor.

WITNESS my hand and Notarial Seal this day of , 20 .

Notary Public

My Commission Expires: Date

My County of Residence: Date

Doctor’s Information

Doctor’s Name:

Doctor’s Address:

Doctor’s Office Phone:

Doctor’s Emergency Phone:

Allergies to Medications:

Allergies (Other):

Conditions for which the child is currently receiving treatment:

Note any other significant medical information:

Insurance Information

Medical Insurer/Health Plan:

Policy Holder:

Policy #:

Group #:

Parent(s)/Legal Guardian(s)

Parent #1:

Name:

Address:

Home phone:

Work phone:

Cell phone:

Email:

Parent #2:

Name:

Address:

Home phone:

Work phone:

Cell phone:

Email:

Alternate Contact(s) in the Event Parent(s)/Legal Guardian(s) Cannot be Reached

Name:

Address:

Home phone:

Work phone:

Cell phone:

Email:

Name:

Address:

Home phone:

Work phone:

Cell phone:

Email: