Medical Treatment Authorization Form (Page 2 of 2) in pdf

Medical Treatment Authorization Form Page 2

Health Insurance Information

Policy Holder’s Name

Insurance Company

Policy Number

Phone Number

Medical Doctor

Phone Number

Emergency Contacts

Name of persons and telephone numbers to call in case of emergency:

Parent/Guardian

Home______________ Work______________ Cell

Parent/Guardian

Home______________ Work______________ Cell

Other

Home______________ Work______________ Cell

Other Information

Other information leaders should know about the child participant:

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the child named above may be in need of first aid or

emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do

hereby give permission for agents of this program to seek and secure any needed medical attention or

treatment for the child named above including hospitalization, if in the agent’s opinion such need arises.

In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment.

I give permission for attending physician(s) and other medical personnel to administer any needed

medical treatment, including surgery and, again, I agree to pay for the medical treatment.

I give permission to transport the child named above to a medical treatment center in a non-emergency

vehicle in a medical emergency situation.

Signature of Parent or Legal Guardian

Date

Print Name of Parent or Legal Guardian

Witness Signature

Date

Medical Treatment Authorization Form Page 2