Authorization Form For Medical Treatment Of Minors printable pdf download

AUTHORIZATION for medical treatment of minors

If your child needs medical, dental, health or hospital services, under law, you as a parent must give permission.

Naturally, if you are with your child you can give permission as the need arises. You can prepare for those unexpected

times when you are not with your child by filling out this authorization form. Using this form, you can give permission to

other adults to act for you, in you absence, regarding the treatment of your child. This is a legal document. After you

complete this form, give a copy to each adult you have named to act on your behalf. If your child needs unexpected

medical treatment, the responsible adult should present this document to the appropriate person -- physician, dentist, or

hospital representative.

When a true emergency exists a child may be treated without parental consent. This will happen when a physician

determines the child needs immediate medical care and that an attempt to obtain parental consent would result in a delay

which would increase the risk to the child’s life or health.

PLEASE COMPLETE ALL SECTIONS

A. IDENTIFICATION

Name of Minor _____________________________

Date of Birth ____________________________

B. ALLERGIES

If your child has allergies, indicate if your child

does or

does

not have an allergic reaction kit for any of the listed allergies. If

My child has the following allergies or medical conditions (if

your child does, attach specific instructions to this form and indicate

none, write NONE):__________________________________

whether the child or the coach/chaperone will keep the kit.

C. MEDICATIONS, INCLUDING INHALERS

Medication Dosage (amount and frequency)

Medication

Prescription

Over-the-Counter

Name:

Prescription

Over-the-Counter

Name:

Prescription

Over-the-Counter

Name:

My child uses inhalers as described above for respiratory ailments, and

does or

does not have my permission to keep this with him/her. If your child does not, then the coach/chaperone

will keep it with him or her.

D. HEALTH CONDITIONS

Describe any health conditions or other health information that would help us treat your child in your absence:

_____________________________________________________________________________________________________________________

Emergency contact name if parents are unavailable: __________________________ Phone# _________________

Insurance Co. or Gov. Program ID/Contract#_______________________

Name of Ins. Plan________________________________ Physician’s Name ________________________________

Physician’s Phone#__________________________

Address___________________________________

I, being the parent, custodian or legal guardian of the above named minor, do hereby appoint the Club President,

Head Coach or designated parent chaperone, to act on my behalf in authorizing unexpected medical, dental,

surgical care and hospitalization for the above named minor in my absence.

Printed Name___________________________ Signature _____________________________Date_________________

Phone(H)________________Work)________________________ (Cell)_______________________

Street Address____________________________________City___________________ State_______ Zip ___________

Form valid for a period of one year from date signed

Authorization Form For Medical Treatment Of Minors

Related Articles

Related forms

Related Categories