Authorization: For Minor's Medical Treatment

AUTHORIZATION & CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

I do hereby solemnly swear that I have legal custody of the aforementioned minor child.

I grant my authorization and consent for _________ (hereafter “Supervising Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.

It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

This authorization is effective commencing on the ______day of ________, 20___ and expiring on the ______day of ________, 20___.

Signed this ______day of___________, 20 ____.

_____________________________
Parent #1’s Signature

_____________________________
Parent #2’s Signature

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

STATE OF __________________

COUNTY OF ________________

This document was acknowledged before me on _______ [date] by _______________ [name of principal].

[Notary Seal, if any]:

_____________________________
(Signature of Notarial Officer)

Notary Public for the State of ______________

My commission expires: __________________