AUTHORIZATION for medical treatment of minors
If your child needs medical, dental, health or hospital services, under law, you as a parent must give permission.
Naturally, if you are with your child you can give permission as the need arises. You can prepare for those unexpected
times when you are not with your child by filling out this authorization form. Using this form, you can give permission to
other adults to act for you, in you absence, regarding the treatment of your child. This is a legal document. After you
complete this form, give a copy to each adult you have named to act on your behalf. If your child needs unexpected
medical treatment, the responsible adult should present this document to the appropriate person -- physician, dentist, or
When a true emergency exists a child may be treated without parental consent. This will happen when a physician
determines the child needs immediate medical care and that an attempt to obtain parental consent would result in a delay
which would increase the risk to the child’s life or health.
PLEASE COMPLETE ALL SECTIONS
Name of Minor _____________________________
Date of Birth ____________________________
If your child has allergies, indicate if your child
not have an allergic reaction kit for any of the listed allergies. If
My child has the following allergies or medical conditions (if
your child does, attach specific instructions to this form and indicate
none, write NONE):__________________________________
whether the child or the coach/chaperone will keep the kit.
C. MEDICATIONS, INCLUDING INHALERS
Medication Dosage (amount and frequency)
My child uses inhalers as described above for respiratory ailments, and
does not have my permission to keep this with him/her. If your child does not, then the coach/chaperone
will keep it with him or her.
D. HEALTH CONDITIONS
Describe any health conditions or other health information that would help us treat your child in your absence:
Emergency contact name if parents are unavailable: __________________________ Phone# _________________
Insurance Co. or Gov. Program ID/Contract#_______________________
Name of Ins. Plan________________________________ Physician’s Name ________________________________
I, being the parent, custodian or legal guardian of the above named minor, do hereby appoint the Club President,
Head Coach or designated parent chaperone, to act on my behalf in authorizing unexpected medical, dental,
surgical care and hospitalization for the above named minor in my absence.
Printed Name___________________________ Signature _____________________________Date_________________
Street Address____________________________________City___________________ State_______ Zip ___________
Form valid for a period of one year from date signed