Authorization for Minor's Medical Treatment
Child
Name: ______________________________
Birthdate: ____________________	Age: _________	Grade in school: ____________
Doctor (or HMO): ______________________________
Address:	______________________
______________________
Phone: ____________________
Medical Insurer/Health Plan: _______________________	Policy #: _________________
Allergies (medications): ______________________________
Allergies (other): ____________________________________
Conditions for which child is currently receiving treatment: 
__________________________________________________________________
Other important medical information:
__________________________________________________________________
Dentist: ______________________________
Address:	______________________
______________________
Phone: ____________________
Dental Insurer/Plan: ______________________________	Policy #: _________________

Parents (or Legal Guardians)

Parent 1
Name: ____________________
Address:	______________________
______________________
Home phone: ____________________	Work phone: ____________________
Cell phone or pager: ____________________	Email: ____________________
Additional Contact Information: ___________________________

Parent 2
Name: ____________________
Address:	______________________
______________________
Home phone: ____________________	Work phone: ____________________
Cell phone or pager: ____________________	Email: ____________________
Additional Contact Information: ___________________________

Other Adult to Notify in Case Parent(s) Cannot Be Reached
Name: ____________________
Address:	______________________
______________________
Home phone: ____________________	Work phone: ____________________
Cell phone or pager: ____________________	Email: ____________________
Additional Contact Information: ___________________________

Authorization and Consent of Parent(s) or Legal Guardian(s)

I affirm that I have legal custody of the minor child indicated above. I give my authorization and consent for __________________________ [name of supervising adult], who is a(n) _____________ [title and name of organization, if appropriate], to authorize necessary medical or dental care for my child. Such medical treatment shall be provided upon the advice of and supervision by any physician, surgeon, dentist, or other medical practitioner licensed to practice in the United States.

Parent 1's signature: ____________________________________	Date: ______________

Parent 2's signature: ____________________________________	Date: ______________

Certificate of Acknowledgment of Notary Public

State of _______________________________	)
	)	ss
County of _____________________________	)
On _____________________, before me, ______________________________, a notary public in and for said state personally appeared ___________________ ________________________, known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument, and acknowledged to me that he or she executed the same in his or her authorized capacity and that by his or her signature on the instrument, the person, or the entity upon behalf of which the person acted, executed the instrument.
	WITNESS my hand and official seal.
	_____________________________________
	Notary Public for the State of ______________
	My commission expires __________________
[NOTARY SEAL]