MEDICAL TREATMENT AUTHORIZATION LETTER Page 1of 1 …
MEDICAL TREATMENT AUTHORIZATION LETTER MEDICAL TREATMENT AUTHORIZATION LETTER
Page 1 of 1
GUARDIAN'S NAME
GUARDIAN'S ADDRESS
GUARDIAN' S HOME & CONTACT INFO
Date:
To Whom It May Concern:
Our minor child(ren) ___________________________________________, will be traveling with and under the temporary guardianship of:
Name(s): ________________________________________________________ Relationship: _____________________________________________________ Address: ________________________________________________________ During the Dates of: _______________________________________________
In case of medical emergency during our absence, please try to reach the children's parents/guardians first at these numbers:
Name:___________________ Relationship:____________ Phone: ____________
Name:___________________ Relationship:____________ Phone: ____________
In the event that none of the legal guardians noted above can be reached by phone during a medical emergency, we authorize (Names): ___________________________________________________________________ to make any medical decisions necessary to ensure proper treatment. We will assume all expenses related to the medical care for our child(ren). The following minors: ________________________________ are covered by a medical insurance policy issued by: ___________________________________________ Insured Name: ____________________________ Policy ID: _________________ Insurance Company Phone: ___________________________________________ Minors' Physician Contact Info: ________________________________________
__________________________________________________________________
Thank you.
Parent/Guardian
Parent/Guardian
................
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