Medical Treatment Authorization Form printable pdf download

Medical Treatment Authorization Form

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.

I do hereby state that I have legal custody of the below named minor. I grant my authorization and

consent for _________________________________________ (name both host parents) 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 aforementioned adults 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 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 all

expenses (exceeding insurance benefits, if applicable) 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 host parent in the exercise of his or her best judgment

upon the advice of any such medical or emergency personnel.

This authorization is effective through __________________ (typically June of graduation year).

Signed this ___________ day of ____________, 20___.

Student Name ________________________________________________________________________

Signature of Mother_________________________________________ Date _______________

Signature of Father __________________________________________ Date _______________

Signature of Translator (or Witness)_____________________________ Date ________________

Medical Treatment Authorization Form