Medical Treatment Authorization Letter

Medical   T reatment   A uthorization   L etter  

(This   l etter   s hould   b e   g iven   t o   t he   g uardian   o r   g roup   l eader   d uring   t he   e ntire   t rip.)  

 

Parent/Guardian   N ame:   _ ____________________________________________________________________________________  

 

Parent/Guardian   A ddress:   _ __________________________________________________________________________________  

 

Parent/Guardian’s   P hone   N umbers:   _ _______________________________________________________________________  

 

Date:   _ _________________________________________________  

 

To   W hom   I t   M ay   C oncern:  

Our   c hild   _ ________________________________________________________   D OB:   _ ______________________________________  

 

Will   b e   t raveling   w ith   a nd   u nder   t he   t emporary   g uardianship   o f  

 

The   G lobal   L eadership   I nstitute  

Summer   L eadership   T our   l ed   b y  

Dr.   L eAnne   C ampbell    

PO   B ox   7 1224,   D urham,   N C   2 7712  

 

During   t he   d ates   o f:   _ __________________________________________________________________________________________  

 

In   c ase   o f   m edical   e mergency   d uring   o ur   a bsence,   p lease   t ry   t o   r each   c hildren’s   p arents/guardians  

first   a t   t hese   n umbers:  

 

Name:   _ ___________________________________________   R elationship:__________________   P hone:____________________  

 

Name:   _ ___________________________________________   R elationship:__________________   P hone:   _ __________________  

 

In   t he   e vent   t hat   n one   o f   t he   l egal   g uardians   n oted   a bove   c an   b e   r eached   b y   p hone   d uring   a   m edical  

emergency,   w e   a uthorize,   D r.   L eAnne   D isla,   t o   m ake   a ny   m edical   d ecisions   n ecessary   t o   e nsure  

proper   t reatment.   W e   w ill   a ssume   a ll   e xpenses   r elated   t o   m edical   c are   f or   o ur   c hild.  

 

Our   c hild:   _ __________________________________________________________   i s   c overed   b y   a   m edical   i nsurance    

 

policy   i ssued   b y:   _ _________________________________________   I nsured   N ame:   _ _________________________________  

 

Policy   I D:_________________________________________   I nsurance   C ompany’s   P hone:   _ ___________________________  

 

Name   o f   C hild’s   P hysician:   _ _________________________________________   P hone:   _ _______________________________  

 

I   o r   w e   a uthorize   t he   a bove:  

 

Signed:   _ ___________________________________________________     _ ___________________________________________________  

 

          P arent/Guardian  

 

 

 

 

Parent/Guardian  

 

Date:   _ _______________________________________________________________  

 

(This   l etter   n eeds   t o   b e   s igned   b y   b oth   p arents.)