Medical Treatment Authorization Form for Minors

  • 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 parents/guardians cannot be immediately reached.
  • Date Format: MM slash DD slash YYYY
  • Consent for Medical Care / Emergency Treatment

  • I hereby state that I have legal custody of the Minor named above. I grant my authorization and consent for the Camp Director or designee 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 Camp Director or designee to summon professional emergency personnel to attend, transport, and treat the Minor. I voluntarily consent to the rendering of medical care for the Minor including X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis or treatment deemed advisable by licensed medical professionals.

    It is understood that this authorization is given in advance of any such treatment, but is given to provide authority and power on the part of the Camp Director in the exercise of his or her best judgment upon the advice of medical or emergency personnel. I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatments on my child’s condition. I accept financial responsibility for expenses charged in connection with such care and treatment.

  • I hereby give my consent to the Camp / Camp Director noted above to arrange for emergency medical/dental care and treatment necessary to preserve the health of my child while in attendance at the Camp listed above. I have read this form and certify that I understand its contents.
  • Date Format: MM slash DD slash YYYY