Childcare Medical Authorization Form
May 4, 2012 | 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):
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________________________.
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