Medical Authorization Form
Name of the Parent/Guardian
First Name
Last Name
Address of the Parent/Guardian
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of the Parent/Guardian
Email of the Parent/Guardian
example@example.com
Name of the Person to whom you give authority
First Name
Last Name
Address of the person to whom you give authority
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What are the reasons?
Authorization start date
-
Month
-
Day
Year
Date
Authorization end date
-
Month
-
Day
Year
Date
Parent/Guardian Signature
Submit
Should be Empty: