Rise High Elite, LLC

Authorization to Consent to Medical Treatment of Minor Child

If you intend to leave your minor children with a family member, coach or another person for an extended time, the following form authorizes the person to whom you entrust the child's care to obtain medical treatment for your minor child in your absence.

During our absence from February 2018 through August 2018, we hereby delegate

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Subject

Message

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

To authorize any medical or surgical treatment which may be required for our child/children during our absence?

Child's Name

First Name

Last Name

DOB

MM

DD

YYYY

Allergies? (if any)

Last tetanus shot?

MM

DD

YYYY

Chronic illness? (if any)

Current Meds? (if any)

Family Physician

First Name

Last Name

Specialty Physician? (Ortho, ENT, Plastic, etc.)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Insurance information helps facilitate proper billing in your absence.

Name of Insurance Co.

Policy #, class, group #

Name of Insured

Place of Employment

Religion

Mother's Signature

By checking this box, I certify that the above text permits as the mother's signature

Father's Signature

By checking this box, I certify that the above text permits as the father's signature

Date Signed

MM

DD

YYYY

Rise High Elite, LLC

Authorization to Consent to Medical Treatment of Minor Child

During our absence from February 2018 through August 2018, we hereby delegate

Download: Medical Treatment consent

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