Temporary Authorization to Consent to Treat a Child

 
I (we)_____________________________________________________________   
                   Name(s) and address(es) of parents 

designate to _______________________________________________________
                      Name and address of designee 
the power to consent in our absence to medical care for our 
child(ren): 

_________________________________    _______________________________ 
Name(s) and age(s) of  child(ren) 

_________________________________    _______________________________ 

Parent(s)' phone number: __________________________________________ 
Child(ren)'s physician(s): ________________________________________ 
Physician's address and phone number: _____________________________ 
___________________________________________________________________ 
Medical insurance company: ________________________________________
Policy #: _________________________________________________________ 
Dates of expected absence from ________________ to ________________ 

CHILD(REN)'S MEDICAL HISTORY 

Chronic conditions________________________________________________ 
Medications that need to be given on a regular basis: 
___________________     __________________________________________ 
Child's Name             Medication name, dosage, frequency 
___________________     __________________________________________ 
Child's Name             Medication name, dosage, frequency 
___________________     __________________________________________ 
Child's Name             Medication name, dosage, frequency 

Allergies:________________________________________________________ 
Dietary or other restrictions: ___________________________________