Medical Authorization For Minor printable pdf download

Medical Authorization For Minor

Diocese of Venice

1000 Pinebrook Road, Venice, FL 34285

(941) 484-9543

MEDICAL AUTHORIZATION FOR MINOR

NAME OF MINOR: __________________________________ D.O.B. _________________

PARISH: ___________________________________________________________________

HOME ADDRESS: ___________________________________________________________

________________________________________________________________

PARENTS/GUARDIANS: ______________________________________________________

PHONE #s: WORK _____________________________ HOME: _______________________

CELL: ____________________________

EMERGENCY CONTACT: ____________________________________________________

PHONE: ________________________________________________________

MEDICAL INFORMATION: Please list all pertinent information concerning any special health

conditions your child may have, or other information you would like us to have in an emergency

(blood type, for instance). Severe allergies and all medications your child routinely takes should

be listed here.

______________________________________________________________________________

Child’s Doctor: ____________________________ Phone: _____________________________

Address: ______________________________________________________________________

In case of illness or injury of the above student, all reasonable efforts will be made to contact the

parent(s)/legal guardian(s)/emergency contact. In case of a medical emergency when these

parties cannot be notified or are not available, I (we) authorize the parish to consent to any x-ray

examination, anesthetic, medical or surgical treatment, and/or hospital care, as determined to be

necessary and appropriate by a licensed physician in the State of Florida. This authorization is

valid for a period of 1 year from the date of execution.

____________________________________

Signature of Parent of Legal Guardian

Signature of Parent or Legal Guardian

R:EducationDOCSEd. DepartmentFORMSMedical Authorization for Minor Sept 2010.wpd

Medical Authorization For Minor