Power Of Attorney For Minors Page 2
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1
2GOING ON VACATION?
Anytime you are going to be separated from your children, be
sure to leave written permission for emergency treatment on file
with Munson Healthcare. By law, hospital emergency personnel
can do nothing for your child in the event he or she becomes ill
or injured, except in life or death situations, without parental
authorization. Your child's care could be needlessly delayed
while the hospital attempts to contact you. With the proper
consent on file, you assure your child of immediate care should
it be necessary in your absence. Complete the form below and
send or bring it to the Emergency Department. Remove this
portion of the sheet to serve as notice for those caring for your
child that consent is on file, which facility it is on file with, and to
familiarize them with the location of the Munson Healthcare
facility.
MUNSON MEDICAL CENTER
KALKASKA MEMORIAL HEALTH CENTER
1105 SIXTH STREET
419 S. CORAL ST.
TRAVERSE CITY, MI 49684-2386
KALKASKA, MI 49646-9438
(231) 935-5000
(231) 258-7500
MUNSON URGENT CARE
PAUL OLIVER MEMORIAL HOSPITAL
550 MUNSON AVE
224 PARK AVENUE
TRAVERSE CITY, MI 49686
FRANKFORT, MI 49635
(231) 935-8686
(231) 352-9621
EMERGENCY ROOM TREATMENT PERMIT/LIMITED POWER OF ATTORNEY
Please Type or Print
Name(s) of Child or Children:
LAST
FIRST
MIDDLE
BIRTHDATE
LAST
FIRST
MIDDLE
BIRTHDATE
Name of Person giving Consent (PRINT)
LAST
FIRST
MIDDLE
The undersigned does hereby grant to the individuals listed below, (name two adult individuals who will be responsible for the care of your
child or children in your absence.).
NAME OF RESPONSIBLE ADULT
PHONE NUMBER
NAME OF RESPONSIBLE ADULT
PHONE NUMBER
Or in the event neither of these individuals is available, I hereby grant the following individuals, (please indicate).
Munson Healthcare, Physician/Provider
the limited Power of Attorney to act for me and to give the required consents and authorizations for the delivery of medical care, diagnoses
and treatment, including surgical intervention, if necessary, in behalf of my minor children listed above:
for a period of time during my absence from
to
(not to exceed 6 months)
and to do all other necessary things as I might or could do if personally present.
This limited Power of Attorney is given pursuant to the provisions of PA 386 of 1998, Sec 700.5103 of the Estates and Protected Individuals Code and said
Power of Attorney is not to exceed six months.
WITNESS
DATE
PARENT OR GUARDIAN
WITNESS
DATE
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