CHILD MEDICAL CARE AUTHORIZATION

*SAMPLE*

This is to acknowledge that ___________________________________________________
is authorized to obtain whatever medical attention is necessary should my child
_____________________ be injured while in their custody.

Insurance Information:

Insurance Carrier            ____________________
Policy No.                      ____________________
Group No.                      ____________________
Phone No.                     ____________________                              

Medical Information:

Doctor __________________________  Phone _________________________
Dentist __________________________ Phone _________________________

Known Allergies/Allergic Reactions:

  __________________________________________________________________

  __________________________________________________________________

  _________________________________     __________________________          __________
                           (Name)                                         (Signature)                              (Date)