 I keep this for all my nieces and nephews.
Sorry, I don't have any info about guardianship, But this is a form I keep for the kids when they stay with me.
AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT
Child
Full Legal Name: __________________________________________________ _________________
Date of Birth: _______________________ Age: ___________ Gender: __
Doctor’s Information
Doctor’s Name: __________________________________________________ __________________
Doctor’s Address: __________________________________________________ ________________
Doctor’s Office Phone: ____________________ Doctor’s Emergency Phone: __________________
Medical Insurer/Health Plan: __________________________ Policy #: ______________________
Allergies to Medications: __________________________________________________ ___________
Allergies (Other): __________________________________________________ _________________
If applicable, please note the conditions for which the child is currently receiving treatment:
__________________________________________________ _______________________________
Note any other significant medical information:
__________________________________________________ _________________________
Parent(s)/Legal Guardian(s):
Parent #1:
Name: __________________________________________________ _________________________
Address: __________________________________________________ ______________________
Home phone: __________________________ Work phone: ____________________________
Cell phone: ____________________________ Pager: _________________________________
Email: ________________________________
Additional Contact Information: __________________________________________________ _____
Parent #2:
Name: __________________________________________________ _________________________
Address: __________________________________________________ ______________________
Home phone: __________________________ Work phone: ____________________________
Cell phone: ____________________________ Pager: _________________________________
Email: ________________________________
Additional Contact Information: __________________________________________________ _____
Alternate contact in the event Parent(s)/Legal Guardian(s) cannot be reached:
Name: __________________________________________________ _________________________
Address: __________________________________________________ ______________________
Home phone: __________________________ Work phone: ____________________________
Cell phone: ____________________________ Pager: _________________________________
Email: ________________________________
Additional Contact Information: __________________________________________________ _____
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
I do hereby solemnly swear that I have legal custody of the aforementioned minor child.
I grant my authorization and consent for _________________________________________ (hereafter “Supervising Adult”) 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 Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant 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 licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.
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 Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.
This authorization is effective commencing on the ______day of ____________________, 20_____ and expiring on the ______day of ____________________, 20____.
Signed this ______day of____________________, 20 ____.
______________________________________
Parent #1’s Signature
______________________________________
Parent #2’s Signature
__________________
Allison
I have to exercise in the morning, before my brain figures out what the hell I am actually doing
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Traditional PCOS - Anovulatory, increased androgens, no insulin resistance
Medications and Supps listed on my profile.
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