Child Guardianship Form



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CHILD GUARDIAN CONSENT FORM I of , the current legal parent of (child s parent) (parent s city state) born on , hereby appoint (child s name) (child s date of birth) of as legal guardian for my child (guardian s name) (guardian s city and state) for the period of time beginning on and ending on .. Medical Authorization for Minors I, , the parent of or legal guardian of , a minor, do hereby authorize any one or more of , or , as agents for myself in my absence or incapacitation to consent to any x- ray examination and anesthetic, medical or surgical diagnosis or treat m e n t and medical care which is deeme d advisable by and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital whether or not such diagnosis or treat m en t is rendere d at the office of said physician or at said hospital.. Home State of Minors: Minor Legal Name : Birthdate: Minor Legal Name : Birthdate: Minor Legal Name : Birthdate: Minor Legal Name : Birthdate: Minor Legal Name : Birthdate: Parent / G ua r di a n Legal Name (PRINT):




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