Medical Consent Form

Parent/Guardian Name: ____________________________________________________________________

Address: ________________________________________________________________________________

Children:

During my/our absence during the period from ____________________ through _________________, We authorize the following person to consent for all medical and/or surgical treatments and procedures which may be necessary during the aforementioned time period of my/our absence.

Authorized Parties:

Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

We agree to pay for all such services authorized and rendered under this consent form.

Parent Signature: ________________________________________________________________________

Parent Signature: ________________________________________________________________________

Medical Insurance Company: _____________________________________ Policy No. __________________

Nearest Relative: ______________________________________________ Phone: ______________________

Address: __________________________________________________________________________________