Free Affidavit of Parental Consent Template
Affidavit of Parental Consent
I, [YOUR NAME], residing at [YOUR ADDRESS], hereby declare and affirm under penalty of perjury under the laws of [STATE NAME] that I am the legal parent/guardian of [CHILD'S NAME], who was born on [CHILD'S BIRTH DATE].
I hereby authorize and consent to any and all medical treatments, procedures, examinations, and surgeries deemed necessary or advisable by the medical professionals at [HOSPITAL NAME] for my minor child, [CHILD'S NAME], in the event of any medical emergency or condition requiring immediate attention.
This consent includes but is not limited to, the administration of medication, anesthesia, diagnostic tests, surgery, and any other medical procedures that may be required for the well-being and health of my child.
I understand that every effort will be made to contact me in the event of any medical treatment or procedure being necessary for my child. However, in situations where immediate medical attention is required, I authorize the medical staff at [HOSPITAL NAME] to proceed with necessary treatments without delay.
I further understand that this consent will remain valid until revoked in writing by myself, the undersigned parent/guardian.
This Affidavit of Parental Consent is executed on this [DATE].
[YOUR NAME]
[WITNESS' NAME]
State of [STATE NAME]
County of [COUNTY NAME]
On this [DATE], before me, a Notary Public in and for said County and State, personally appeared [YOUR NAME], 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 they executed the same for the purposes therein contained.
[NOTARY PUBLIC NAME]
[NOTARY PUBLIC EXPIRY DATE]
