Child Medical Care Authorization Form
Child Medical Care Authorization Form
Please complete this Child Medical Care Authorization Form Template to grant permission for healthcare providers to administer necessary medical care to your child in your absence.
Caregiver's Full Name
Phone number
Address
Parent(s)/guardian(s) granting this child care authorization. Please list them all.
The caregiver is being granted temporary power over the following children:
|
Name |
Birthdate |
Birthplace |
|
|---|---|---|---|
|
Child 1 |
|
|
|
|
Child 2 |
|
|
|
|
Child 3 |
|
|
|
|
Child 4 |
|
|
|
Caregiver Powers
The caregiver shall have the following powers with regard to the above-named children.
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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
-
To provide food and shelter for the children and to make decisions regarding their day-to-day activities
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To transport the children in the caregiver's car, including authorization to pick the children up from school or daycare
Duration
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Until terminated by the undersigned parents or guardians
-
This authorization will terminate on the date form below
Until Date
Current Date
Parent/Guardian
Name:
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