Childcare Medical Authorization Form


Posted on May 4, 2012 by admin | in Background Check

CHILDCARE MEDICAL AUTHORIZATION

I ________________________ the parent or guardian of the below described minor(s), am legally entitled to give this authorization, grant temporary authority,
limited to the below defined powers, over the following child(ren):

_______________________
Child Name		 ____________
DOB		 __________________
Social Security Number

The powers granted to said are limited to the following:

  • To seek medical care for the children, including, but not limited to, visits to the doctor and/or hospital.
  • To authorize medical treatment or medical procedures in the event of an emergency situation.
  • To provide food and shelter for the above named children, and to make decisions regarding their day-to-day activities.
  • To transport the children in the caregiver’s car, including authorization to pick the children up from school or daycare.
  • This grant of authority is effective as of, and shall remain in effect until terminated by the undersigned parent or guardian.

This grant of authority is signed this _____ day of ________________, 201_, in the County of _____________ State of________________________.

_______________________________
Employer Signature		 _______________________________
Employer Signature
 

  
________________________________
Employer Signature

0saves
Save
If you enjoyed this post, please consider leaving a comment or subscribing to the RSS feed to have future articles delivered to your feed reader.
|