Parental Medical Permission And Release

To Whom it May Concern:

,being the of , whose Date of Birth is , do hereby grant authority to to make decisions regarding medical services to this minor child and permission to medical providers to comply with those decisions. This authority is to apply
The scope of this permission shall be:
ALL Decisions.
Decisions other than removal / non-removal of life support.
Treatment for potentially life threatening illness or injury, or severe pain.
Treatment for potentially life threatening illness or injury ONLY.

This permission is intended to allow medical personel to provide prudent treatment to the above named child while attemps are being made to contact me / us through the below listed numbers.

Responsible party's Employer name:
Responsible party's Incurance Company name:
Insurance policy number:
Group or other ID number:
Special Instructions, allergies, etc.

Contact Phone Numbers

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Father: Alternate:Alternate2:Pager:
Mother: Alternate:Alternate2:Pager:

Father's name:Signature:____________________Date:________
Mother's name:Signature:____________________Date:______