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AUTHORIZATION FOR EMERGENCY MEDICAL CARE

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									                AUTHORIZATION FOR EMERGENCY MEDICAL CARE

In my absence, I authorize

(adult into whose care minor(s) is entrusted)


(family doctor or pediatrician)


to act in my place to consent to medical treatment or hospital care as deemed advisable by any
physician/surgeon licensed in the State of Minnesota.

I assume financial responsibility for the delivery of such care.

Medical insurance company ____________________________________________________

Policy No. __________________________________________________________________

Doctor’s Name _______________________________________ Phone _________________

Child(ren)’s Name(s) Birth Date……. Blood Type Weight Allergies………………….




Address ____________________________________________ Phone ___________________

       Signed ______________________________________________________
              (mother/father/legal guardian)

       Date ________________

       Activity/Class __________________________________________________________

I can be reached at ___________________________________________ Phone _____________

Another person to notify in an emergency ____________________________________________

Relationship ________________________________________________ Phone _____________

								
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