Child Medical Consent and Power of Attorney
1. Child Information
Full Name
Date of Birth
Gender
Address
2. Parent/Legal Guardian Information
Full Name
Relationship
Address
Phone
Email
3. Authorized Person Information
Full Name
Relationship to Child
Address
Phone
Email
4. Medical Information
Physician Name
Physician Phone
Insurance Information
Allergies, Medications, or Special Conditions
5. Consent and Authorization
I, the undersigned parent/legal guardian, grant permission to the authorized person named above to make medical decisions for my child in my absence.
6. Signatures
Parent/Guardian Signature
Date
Authorized Person Signature
Date