make your free medical treatment authorization for a minor form
what is a medical treatment authorization for a minor form?
when to use a medical treatment authorization for a minor form:
- you want to grant medical authorization to a person having temporary responsibility for your child.
- you want to state the amount of authorization and to provide medical and contact information.
- you or your child are taking a trip or will be separated for some other reason and the person responsible for your child needs authority to seek medical treatment.
sample medical treatment authorization for a minor form
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medical treatment authorization for a minor
i, , the authority to obtain medical treatment for the following child(ren):
| name of child: |
| birthdate: |
the above care provider(s) are authorized to:
| other information: |
this grant of temporary authority shall begin on , and shall remain effective
dated:
| by: | date: |
| , |
| preferred phone number: |
| alternate phone number: |
, county of parish of
on this _____ day of ____________________, _____, before me, ______________________________, the undersigned officer, personally appeared ______________________________, known to me (or proved to me on the oath of ______________________________) to be the person who is described in and who executed the within and foregoing , and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
before me, a notary public (or justice of the peace) in and for said county, personally appeared the above named ______________________________, who acknowledged that he/she did sign the foregoing , and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief. in testimony whereof, i have hereunto subscribed my name at ________________________________, this _____ day of ____________________, _____.
the foregoing was acknowledged before me this _____ day of ____________________, _____, by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
the foregoing was acknowledged before me, by means of ☐ physical presence or ☐ online notarization, this _____ day of ____________________, _____ by ______________________________, who is personally known to me or who have produced ________________________________ as identification, and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
this was acknowledged before me on this _____ day of ____________________, _____ by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
on this _____ day of ____________________, _____, before me personally appeared ______________________________, to me known to be the person described in and who executed the foregoing , and, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
on this _____ day of ____________________, _____, before me, ________________________________, personally appeared ______________________________, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within , and, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
on this _____ day of ____________________, _____, before me, the undersigned, notary public for the state of vermont, personally appeared ______________________________, to me known (or to me proved) to be the identical person named in and who executed the above , who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
the foregoing instrument was acknowledged before me this _____ day of ____________________, _____, by ______________________________, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
in witness whereof i hereunto set my hand and official seal.
_________________________________
notary public
signature of person taking acknowledgment
_________________________________
name typed, printed, or stamped
title (and rank)
_________________________________
title or rank
my commission expires _____________
_________________________________
serial number (if applicable)
serial number, if any
notary address:
_________________________________
_________________________________
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