Medical Treatment Authorization Form

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Medical Treatment Authorization Form
This form grants temporary authority to a designated adult to provide and arrange for medical care for a
minor in the event of an emergency, where the minor is not accompanied by either parents or legal
guardians, and it may not be feasible or practical to contact them.
Minor
Full Legal Name:_______________________________________________________________________
Home Address:________________________________________________________________________
Date of Birth:__________________ Gender: Female:_________ Male: ______________
Information for Medical Treatment
Physician’s Name and Location of Practice: _____________________________________________________
Physician’s Phone #: (___)_____________________
Medical Insurer/Health Plan: ________________________ Policy #:__________________
Allergies: _________________________________________________________________________
Please note all conditions for which the child is currently receiving treatment:__________________________
________________________________________________________________________________________
Authorization and consent of Parent(s) or legal guardian(s)
I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for
The Center for Rural Entrepreneurship at Lyndon State College (hereafter “Designated Adult”) or any such
substitute as he/she may designate to administer general first aid treatment for any minor injuries or illnesses
experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize
the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the
minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis,
treatment or hospital care deemed advisable by and to be rendered under the general supervision of, any licensed
physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the
state in which such treatment is to occur. I agree to assume financial responsibility for expenses of such care.
It is understood that this authorization is given in advance of any such medical treatment, but is given to provide
authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the
advice of any such medical or emergency personnel.
This authorization is effective through:________________ Signed ____________ (date)
Parent/Legal Guardian Signature:________________________________
Printed Name: _______________________________________________

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