CHILD CARE AUTHORIZATION
I/We, _____________________________ and ______________________________, the parent(s) or
guardian(s) of the below described minor(s), and legally entitled to give this authorization, grant
_____________________________ temporary authority, limited to the below defined powers, over the
following children:
- _____________________________
- _____________________________
- _____________________________
- _____________________________
The powers granted to said temporary guardian _____________________________ are limited to the
following:
- To seek medical care for the children, including, but not limited to, visits to the doctor
and/or hospital.
- To authorize medical treatment or medical procedures in the event of an emergency
situation.
This grant of authority is effective as of ____/____/____, and shall remain in effect until ____/____/____.
This grant of authority is signed this _____ day of ________________, 2004, in the County of
____________________, State of ____________________.
_______________________________ (Guardian Signature)
_______________________________ (Print Guardian Name)
_______________________________ (Guardian Signature)
_______________________________ (Print Guardian Name)