Medical Permission Slip

Child Medical Consent Form
Parental Information
Name of Father
First NameLast Name
Phone Number of Father
Area CodePhone Number
Email Address of Father
example@example.com
Address of Father
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Mother
First NameLast Name
Phone Number of Mother
Area CodePhone Number
Email Address of Mother
example@example.com
Address of Mother
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Child
First NameLast Name
Date of Birth
MonthDayYear
Date
Gender
Consenting Party
Name of Person/Organization
Address of Person or Organization
Child's Medical Information
Blood Type
Food Allergies (Please Specify)
Drug Allergies (Please Specify)
Name of Pediatrician
Phone Number of Pediatrician
Area CodePhone Number
Insurance
Policy Number
Effectivity Period
Date Start
MonthDayYear
Date
Date End
MonthDayYear
Date
I/We, {nameOf4} and/or {nameOf23}, hereby declare that I am/We are the parent(s)/legal guardian of {nameOf}, who was born on the {dateOf}.
I/We do hereby consent to my child's medical care and the administration determined by a physician to be necessary for the welfare of my/our child while said child is under the care of {nameOf29} of {addressOf}.
This authorization shall be effective from {dateStart} until {dateEnd}.
Signature of Father
Clear
Date signed
MonthDayYear
Date
Signature of Mother
Clear
Date signed
MonthDayYear
Date
Should be Empty:

Child Medical Consent Form