Medical and Educational Custody Authority Form
Child Information
Full Name
Date of Birth
School Name
Address
Parent/Guardian Information
Name
Relationship to Child
Contact Number
Address
Authorized Person
Name
Relationship to Child
Contact Number
Address
Authority Granted
Description of authority granted (medical, educational decisions, etc.)
This authority remains in effect until revoked in writing or on the specified end date below.
Start Date
End Date
Parent/Guardian Signature
Date