Medical Authorization Form

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How to create a Medical Authorization Form? Download this Medical Authorization Form template that will perfectly suit your needs.

When you are looking for a Medical Power of Attorney letter or Sample Medical Authorization letter, to authorize the emergency treatment for someone you love, it's better to start with a professional document template like this one. This will save you time and frustration. Since time and your mood are precious, don't waste it.

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Medical Authorization Form

To Whom It May Concern,

Purpose: To enable parents or guardians to authorize the provision of emergency treatment for their children who are injured or become ill while under the authority of {{Name of chaperone}} in the event the parents or guardians cannot be reached.

This acknowledges that we, the undersigned, parent(s) or legal guardian(s) of {{Name of participant}} recognize the potentially hazardous nature of the sport of ULTIMATE that an injury might be sustained. These injuries include but are not limited to PERMANENT DISABILITY, BLINDNESS, PARALYSIS AND DEATH.

In the event of such an injury to my child and we (I/my spouse/guardian) cannot be contacted, we give permission to qualified and licensed EMTs, physicians, paramedics, certified athletic trainers, and/or other medical or hospital personnel to render such treatment.

Parent/Guardian: Name Printed Signature Date Phone Parent/Guardian: Name Printed Signature Date Phone Family Physician: Name Printed Preferred Hospital: Address Phone Child’s Medical Insurance Carrier: Name Phone Emergency Contact: Name Printed Address Phone Specific facts concerning child’s medical history including allergies, medications being taken, chronic illness or other conditions which a physician should be alerted to: Completed forms should be given to the chaperone..

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DISCLAIMER
Nothing on this site shall be considered legal advice and no attorney-client relationship is established.

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