Emergency Medical Consent Form for Foster Children

Child Information

Full Name

Date of Birth

Gender

Foster Home Address Current Medications Allergies Medical Conditions

Consenting Adult Information

Name Relationship to Child Contact Phone Number Emergency Contact Name Emergency Contact Phone

Physician Information

Physician Name Physician Phone Physician Address

Consent Statement

I authorize necessary medical treatment for the child named above in the event of an emergency when I cannot be contacted. This authorization is valid from

Start Date

End Date

Signature of Consenting Adult

Date