Authorization And Consent Of Parent(S) And/or Physical/legal Guardian(S) printable pdf download

Authorization And Consent Of Parent(S) And/or Physical/legal Guardian(S)

AUTHORIZATION AND CONSENT OF PARENT(S) AND/OR PHYSICAL/LEGAL GUARDIAN(S)

, hereby declare that I have physical and/or legal custody of the below named child(ren).

I am the ________________________________(mother/father) of the below named child(ren).

I hereby grant my full permission for my child to reside and travel with said temporary guardian.

I hereby grant the temporary guardian my full authorization 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 personnel to attend, transport, and treat the

participant 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 hereby grant the temporary guardian my full authorization to consent to any and all treatments recommended by the physician, including

vaccines, at the time of the visit.

This authorization is effective commencing on the

day of

, 20_

and expiring on the

day of

, 20_

. (Without expiration if left blank)

Under penalty of perjury under the laws of the state of Texas, I attest to the truthfulness, accuracy, and validity of the forgoing statement.

CHILD(REN) INFORMATION

Child(ren)’s Names:

Date of Birth:

TEMPORARY GUARDIAN INFORMATION

TEMPORARY GUARDIAN:

Name and Relationship:

Address:

Home/Cell Phone:

Email: