Childcare Medical Authorization Form

Posted on by admin | in Background Check


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
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

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