TEMPORARY MEDICAL TREATMENT AUTHORIZATION FOR MINORS
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Effective Date: ________________________________________________________
Place: _________________________________________________________________

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1. Parties
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This document is made on ____________________ (____________________) by:

Parent / Legal Guardian
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

In favor of:

Caregiver
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

2. SUBJECT-MATTER SCHEDULE & SPECIFICATIONS
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Child's Full Name & Date of Birth:
    ____________________________________________________________________
Treatment Authorized: __________________________________________________
Allergies & Medical Conditions: ________________________________________
Health Insurance Details: ______________________________________________
Authorization Valid Until: _____________________________________________

3. EXECUTION & SIGNATURES
-------------------------

Parent / Legal Guardian

Signature: _____________________________________________________________

Full Legal Name: _______________________________________________________
Date: __________________________________________________________________