Preview Medical Authorization Letter

MEDICALTREATMENTAUTHORIZATIONLETTER

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:____________

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.

GUARDIAN’SNAME



GUARDIAN’SADDRESS



GUARDIAN’ SHOME&

CONTACTINFO



Parent/Guardian Parent/Guardian

Page 1 of1MEDICALTREATMENTAUTHORIZATIONLETTER

http://www.familytravelforum.com/assets/medicalpermissionletter.html

HTML Preview Medical Authorization Letter page number 1.