Parents or Guardians

Information of Parent/Guardian

(Leave field(s) blank if none.)

Emergency Contact Information of Parents/Guardians

Where can you be contacted in case of emergency?

Health Care Treatment


I authorize my temporary guardian to consent to any of the following health care examinations/treatments for my child/children:

Temporary Guardian(s)

Information of Temporary Guardian

Children

Information of Child

(e.g. Policy number, group, plan, etc.)

Effective Dates

Family Physician

Signing Details

(The temporary guardian or guardians should not be your witnesses.)