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OTHER NAMES Medical Authorization for Minors Authorization for Medical Treatment for a Minor

What is a Medical Treatment Authorization for a Minor Form?

Some children are accident-prone, some will never make you worry, but all should be protected by a Medical Treatment Authorization for a Minor while you're away. You would only leave your children with a childcare provider or a parent or guardian you trust, so it's important they have the authorization to seek medical attention should anything happen. This Medical Treatment Authorization for a Minor authorizes a childcare provider or another parent or guardian to seek medical attention on behalf of your child should anything happen while under their supervision.

When to use a Medical Treatment Authorization for a Minor Form:

  • You want to grant medical authorization to a person having temporary responsibility for your child.
  • You want to state the amount of authorization and to provide medical and contact information.
  • You or your child are taking a trip or will be separated for some other reason and the person responsible for your child needs authority to seek medical treatment.

Sample Medical Treatment Authorization for a Minor Form

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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:

_________________________________

_________________________________

_________________________________

_________________________________

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