Medical Authorization For Minor


Diocese of Venice
1000 Pinebrook Road, Venice, FL 34285
(941) 484-9543
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


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