Alternate Caregiver Permission

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Authorization for Contact

I,	(Name*)	, authorize	(Name*)	(Relationship*)
to act on my behalf regarding my child(ren) as specified below:

 

Child Information

Child's Name:*			DOB 1:*
Child's Name:			DOB 2:
Child's Name:			DOB 3:
Child's Name:			DOB 4:
Child's Name:			DOB 5:

 

Authorize How to Contact

Call the office and give and receive medical information. Bring my child(ren) to the office for a scheduled appointment, give and receive information and make medical decisions in the event that I am unable to be reached. This includes signing the the consent form for regularly scheduled vaccines in the event that I am not present. To act on my behalf in the event that I cannot be reached when seeking emergency medical treatment including that in the emergency room.

 

Authorization Signature

Parent/Guardian Signature:*

Relationship:*

Date:*

CalendarToday

 

Other Contact Number(s) For Parents:

Contact Numbers For Parents

1.	Name:			Relationship:			Number:
2.	Name:			Relationship:			Number:
3.	Name:			Relationship:			Number:
4.	Name:			Relationship:			Number:

Security code: