Authorization for Minor's Medical Treatment
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Medical Treatment Authorization Form
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 parents or legal
guardians, and it may not be feasible or practical to contact them. This form should be given to the trip
leader or shown to the trip leader and then carried by the designated adult.
Minor
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 #: ______________