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MEDICAL TREATMENT AUTHORIZATION FOR A MINOR
I, , the authority to obtain medical treatment for the following child(ren):
| Name of Child: |
| Birthdate: |
The above care provider(s) are authorized to:
| Other Information: |
This grant of temporary authority shall begin on , and shall remain effective
Dated:
| By: | Date: |
| , |
| Preferred Phone Number: |
| Alternate Phone Number: |
, COUNTY OF PARISH OF
On this _____ day of ____________________, _____, before me, ______________________________, the undersigned officer, personally appeared ______________________________, known to me (or proved to me on the oath of ______________________________) to be the person who is described in and who executed the within and foregoing , and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
Before me, a Notary Public (or justice of the peace) in and for said county, personally appeared the above named ______________________________, who acknowledged that he/she did sign the foregoing , and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief. In testimony whereof, I have hereunto subscribed my name at ________________________________, this _____ day of ____________________, _____.
The foregoing was acknowledged before me this _____ day of ____________________, _____, by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
The foregoing was acknowledged before me, by means of ☐ physical presence or ☐ online notarization, this _____ day of ____________________, _____ by ______________________________, who is personally known to me or who have produced ________________________________ as identification, and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
This was acknowledged before me on this _____ day of ____________________, _____ by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
On this _____ day of ____________________, _____, before me personally appeared ______________________________, to me known to be the person described in and who executed the foregoing , and, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
On this _____ day of ____________________, _____, before me, ________________________________, personally appeared ______________________________, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within , and, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
On this _____ day of ____________________, _____, before me, the undersigned, Notary Public for the State of Vermont, personally appeared ______________________________, to me known (or to me proved) to be the identical person named in and who executed the above , who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
The foregoing instrument was acknowledged before me this _____ day of ____________________, _____, by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
In witness whereof I hereunto set my hand and official seal.
_________________________________
Notary Public
Signature of person taking acknowledgment
_________________________________
Name typed, printed, or stamped
Title (and Rank)
_________________________________
Title or rank
My commission expires _____________
_________________________________
Serial number (if applicable)
Serial number, if any
Notary Address:
_________________________________
_________________________________
_________________________________
_________________________________
Document the terms of your child care agreement
Give consent for your child to get medical care
Provide crucial information to a nanny or sitter
Designate a temporary guardian for your child
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Yes, in order to be legally binding, a Consent for Medical Treatment of a Minor document needs to be notarized. Both parents may want to sign the document, if possible.
The four types of consent are:
This Consent for Medical Treatment of a Minor document is an example of express consent because it is giving an authorized individual permission to provide express consent to medical care or treatment for your child(ren).
The primary difference between these documents is marked by the authorization type, travel vs. medical. A medical authorization is specific to your child's healthcare needs, while travel authorization allows your child to travel under the care of whomever you, as the parent or guardian, name in the Travel Consent document.
