Approved CMC Council 8-15-17
This form grants temporary authority to a designated adult to provide, arrange for, and if necessary transport to medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardian, and the parents or legal guardian are unable to be contacted. This form should be given to the trip leader or shown to the trip leader and then carried by the designated adult.
Full Legal Name: ____________________________________________________________________
Home Address: ______________________________________________________________________
Date of Birth: ____________________________ Gender: Female _______ Male _________
Information for Medical Treatment
Physician’s Name and Location of Practice: ______________________________________________
Physician’s Phone # (if known): ______________________________
Medical Insurer/Health Plan: ___________________________ Policy #: _________________________
Allergies to Medications: ________________________________________________________________
Allergies (Other): ______________________________________________________________________
Please note all conditions for which the child is currently receiving treatment: ___________________
Note any other significant medical information: ______________________________________________
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for __________________________________________ (hereafter “Designated Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the Minor, and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care.
It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.
This authorization is effective through: ____________________. Signed this ___ day of ____ 20___
Parent/Legal Guardian Signature: ____________________ Printed Name: _______________________
Witness Signature: __________________________ Printed Name:___________________________