Child Medical Care Authorization Form
Full name of the caregiver to whom temporary power is being granted
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent(s)/guardian(s) granting this child care authorization. Please list them all.
The caregiver is being granted temporary power over the following children
Rows
Full Name
Birthdate
Birthplace
Child 1
1
2
3
Child 2
4
5
6
Child 3
7
8
9
Child 4
10
11
12
Caregiver Powers
The caregiver shall have the following powers with regard to the above-named children.
To seek medical care for the children, including, but not limited to, visits to the doctor and/or hospital
To authorize medical treatment or medical procedures in the event of an emergency situation
To provide food and shelter for the children and to make decisions regarding their day-to-day activities
To transport the children in the caregiver's car, including authorization to pick the children up from school or daycare
Other
Duration
Until terminated by the undersigned parents or guardians
This authorization will terminate on the date from below
Until Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: