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Authority applies during emergencies when the minor is not accompanied by parents or legal guardians and contacting them is not feasible.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What medical details does the form request for the minor?",{"text":114,"@type":110},"The form requests the minor’s full legal name, home address, date of birth, gender, physician name and practice location, physician phone (if known), insurance/health plan details (policy number and insurance card copy), medication allergies and other allergies, and any conditions currently being treated, plus other significant medical information.",{"name":116,"@type":107,"acceptedAnswer":117},"What treatments and emergency actions does the parent or legal guardian consent to?",{"text":118,"@type":110},"The signer authorizes general first aid for injuries or illnesses, and if life threatening, authorizes calling professional emergency personnel and consenting to diagnosis and treatment decisions such as X-rays, anesthesia, blood transfusions, medication, and hospital care under supervision of licensed medical professionals or institutions. 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This form should be given to the trip leader or shown to the trip leader and then carried by the designated adult.  \nMinor  \nFull Legal Name:  Home Address:    \nDate ofBirth:   Gender:  Female  Male  \nInformation for Medical Treatment  \nPhysician’s Name and Location of Practice:   \n____________________________________________________________________________________  \nPhysician’s Phone \\# (if known) ( )   \nMedical Insurer/Health Plan:   Policy \\#:   Copy of Insurance Card  \nAllergies to medications:  \nAllergies (Other):  \nPlease note all conditions for which the child is currently receiving treatment:  \nNote any other significant medical information:  \n________________________________________________________________  \n______________________________________________________________________  \nAUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)  \nI do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for   (hereafter “Designated Adult”) toadminister 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 Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the Minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care.  \nIt is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.  \nThis authorization is effective through:   Signed this   day of   , 20  Parent/ Legal Guardian Signature:  Printed Name:  Address:  Telephone \\#:(  )   \n\n| Notary |  |\n| --- | --- |\n| County | Exp. Date |\n\n_______________________________  \nAddress","cbCaio2meXZKXA7E","https://ap.wps.com/l/cbCaio2meXZKXA7E","pdf",150682,"English","# Minor Information\n## Information for Medical Treatment\n## Authorization and Consent of Parent(s) or Legal Guardian(s)\n# Signature and Notary (If Applicable)","[{\"question\":\"Who is the designated adult and when can they act under this form?\",\"answer\":\"The designated adult is the person temporarily authorized to provide and arrange medical care for the minor. Authority applies during emergencies when the minor is not accompanied by parents or legal guardians and contacting them is not feasible.\"},{\"question\":\"What medical details does the form request for the minor?\",\"answer\":\"The form requests the minor’s full legal name, home address, date of birth, gender, physician name and practice location, physician phone (if known), insurance/health plan details (policy number and insurance card copy), medication allergies and other allergies, and any conditions currently being treated, plus other significant medical information.\"},{\"question\":\"What treatments and emergency actions does the parent or legal guardian consent to?\",\"answer\":\"The signer authorizes general first aid for injuries or illnesses, and if life threatening, authorizes calling professional emergency personnel and consenting to diagnosis and treatment decisions such as X-rays, anesthesia, blood transfusions, medication, and hospital care under supervision of licensed medical professionals or institutions. The signer also agrees to assume financial responsibility for related expenses.\"}]","Medical Treatment Authorization Form | PDF",1789633920]