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.