This document authorizes specific individuals to consent to any necessary emergency medical care for the parent or guardian's child(ren) during a given time period. It provides contact information for the child(ren)'s physician and hospital preference, as well as emergency contact numbers and insurance/medical assistance details. Medical information on the child(ren), such as allergies and immunization history, is also included.

1. AUTHORIZATION FOR EMERGENCY MEDICAL CARE
In order to meet all legal requirements, I hereby authorize ____________________
and/or ___________________________________ to give consent for any and all
necessary emergency medical care for my child(ren) ________________________
__________________________________________________________________
while said child(ren) is (are) in said individual’s custody between the dates of
___________ 20 ____ and __________ 20 ___ .
__________________________
Signature of Parent or Guardian
__________________________
Witness
Physician:__________________________ Address: ________________________
Phone: _________________ Hospital Preference:__________________________
Emergency Phone Numbers: __________________________________________
Do you have health insurance? ________ Policy Name: _____________________
Policy Number: ____________________
Do you receive medical assistance? ____ Card Number: _____________________
Is child eligible for military care? _______ ID Number: _______________________
Medical Information on Child:
Drug Allergies: ______________________________________________________
Last Tetanus Toxoid: _________________________________________________