MAKE YOUR FREE Medical Treatment Authorization for a Minor Form

Create Your Document In Just 3 Easy Steps:

Build your document

Answer a few simple questions to make your document in minutes

Save now, finish later

Start now and save your progress, finish on any device

RocketSign® & use

Securely sign online and invite others to sign

OTHER NAMES Medical Authorization for Minors Authorization for Medical Treatment for a Minor

What is a Medical Treatment Authorization for a Minor Form?

Some children are accident-prone, some will never make you worry, but all should be protected by a Medical Treatment Authorization for a Minor while you're away. You would only leave your children with a childcare provider or a parent or guardian you trust, so it's important they have the authorization to seek medical attention should anything happen. This Medical Treatment Authorization for a Minor authorizes a childcare provider or another parent or guardian to seek medical attention on behalf of your child should anything happen while under their supervision.

When to use a Medical Treatment Authorization for a Minor Form:

You want to grant medical authorization to a person having temporary responsibility for your child.
You want to state the amount of authorization and to provide medical and contact information.
You or your child are taking a trip or will be separated for some other reason and the person responsible for your child needs authority to seek medical treatment.

This document has been customized over 29.4K times

Legally binding and enforceable

Ask a lawyer questions about your document

MEDICAL TREATMENT AUTHORIZATION FOR A MINOR

I, , the authority to obtain medical treatment for the following child(ren):


	Name of Child:


	Birthdate:

The above care provider(s) are authorized to:


	Other Information:

This grant of temporary authority shall begin on , and shall remain effective

Dated:


By:	Date:


		,


	Preferred Phone Number:


	Alternate Phone Number:

, COUNTY OF PARISH OF

On this _____ day of ____________________, _____, before me, ______________________________, the undersigned officer, personally appeared ______________________________, known to me (or proved to me on the oath of ______________________________) to be the person who is described in and who executed the within and foregoing , and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

Before me, a Notary Public (or justice of the peace) in and for said county, personally appeared the above named ______________________________, who acknowledged that he/she did sign the foregoing , and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief. In testimony whereof, I have hereunto subscribed my name at ________________________________, this _____ day of ____________________, _____.

The foregoing was acknowledged before me this _____ day of ____________________, _____, by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

The foregoing was acknowledged before me, by means of ☐ physical presence or ☐ online notarization, this _____ day of ____________________, _____ by ______________________________, who is personally known to me or who have produced ________________________________ as identification, and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

This was acknowledged before me on this _____ day of ____________________, _____ by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

On this _____ day of ____________________, _____, before me personally appeared ______________________________, to me known to be the person described in and who executed the foregoing , and, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

On this _____ day of ____________________, _____, before me, ________________________________, personally appeared ______________________________, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within , and, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

On this _____ day of ____________________, _____, before me, the undersigned, Notary Public for the State of Vermont, personally appeared ______________________________, to me known (or to me proved) to be the identical person named in and who executed the above , who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

The foregoing instrument was acknowledged before me this _____ day of ____________________, _____, by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

In witness whereof I hereunto set my hand and official seal.

_________________________________

Notary Public

Signature of person taking acknowledgment

_________________________________

Name typed, printed, or stamped

Title (and Rank)

_________________________________

Title or rank

My commission expires _____________

_________________________________

Serial number (if applicable)

Serial number, if any

Notary Address:

_________________________________