What is a children’s emergency medical care authorization form?

A children’s emergency medical care authorization form is a form many parents use to state their approval for emergency medical care for their child if they are unable to be reached. An authorization letter parents have used is similar to the following:

TO WHOM IT MAY CONCERN: As the parents of (name) _____________, (address) ____________, we authorize the bearer of this letter to approve medical treatment for our son/daughter if it is required and we are unable to be reached. Our home telephone number is ________ and our work telephone numbers are (father) _______ and (mother) _______. Our health insurance policy is with __________ and the policy number is _______. Our child’s date of birth is _______. He/she is allergic to ____________ or has no allergies we know of. His/her blood type is ____. Our child is being treated for the following conditions: ___________________________. Our pediatrician is Dr. _______________ and the telephone number is _________. Thank you,

Signed ___________________ (mother) ___________________ (father)

Subscribed and sworn to before me this ___ day of _________, .

______________________ Notary Public

____________ County, _______ (state)

Since the laws of each jurisdiction vary, DY recommends that you consult the laws of your jurisdiction to determine the appropriate form for your jurisdiction.