Emergency Medical Treatment Authorization

This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parent/legal guardian, and it may not be feasible or practical to contact them. 


Minor’s Full Legal Name:

Home Address:

Date of Birth: Gender: 

Physician’s Name and Location of Practice:

Physician’s Phone # (if known): (____)________________ 

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 Child’s Parents/legal Guardians

I (We) do hereby state that I (we) have legal custody of the aforementioned Minor. I (We) grant my (our) authorization and consent for the provider or supervising staff (hereafter “Designated Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor while in care at Country Fun Child Care. If the injury or illness is life threatening or in need of emergency treatment, I (we) authorize the Designated Adult to summon any and all necessary 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 of Maine where 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.

Starting Date of Authorization: 

This authorization is effective through: 

Parent/Legal Guardian Signature:

Printed Name:

Witness Signature:

Printed Name: