AUTHORIZATION If your child needs medical care, dental care, or hospital services, you as parent/guardian must give permission. IT IS THE LAW! In an
FOR MEDICAL emergency, your child can only be treated without your consent if a physician determines that your child’s life or health is at risk. Unless a true
TREATMENT OF emergency exists, medical personnel are powerless to help your child without your authorization. That is why you must complete this Medical
MINORS Treatment Authorization form today. You can prepare for the unexpected by giving the band director permission to authorize necessary
treatment for your child during your absence. Complete this form carefully, and have your signature witnessed by a notary public. If your
child needs unexpected treatment, this document will be presented to the physician, dentist, or hospital representative by the authorized adult.
__________________________________________________________________________________________________________________
Full Name of Minor Birth Date Allergies, Special Conditions, or Medications
_______________________________________ ________________ _______________________________
HOSPITALIZATION COVERAGE FOR ABOVE NAMED MINOR:
Insurance or Government Program
______________________________________________________________ I.D. or CONTRACT NUMBER _____________________________
Family Physician / Pediatrician: Name __________________________________________________ Phone ___________________________
Name __________________________________________________ Phone ___________________________
__________________________________________________________________________________________________________________
Notary Public
____________________________________________,the within named parent/guardian of __________________________________________
(Name of Parent/Guardian) (Name of Student)
PERSONALLY APPEARED BEFORE ME, to give permission to Jill Shumaker, Band Director – 101 Short Street Enterprise, MS 39330 Phone: 601-
659-4435 to act on my/our behalf in authorizing unexpected medical, dental, surgical care or appropriate hospital representative for my child at such
time as unexpected medical, dental, surgical care or hospitalization may be required.
__________________________________________________
(Signature of Parent/Guardian)
SWORN TO AND SUBSCRIBED BEFORE ME, THIS THE _________ DAY OF ____________.
___________________________________________________
Notary Public
My Commission Expires:
__________________________