Parent / Legal Guardian Use this form as a Parent or Guardian to allow someone else to have the rights to make health care decisions on your child for a temporary time period. Name of Parent or Legal Guardian First Last *Only 1 Parent / Legal Guardian is required Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Parent / Legal Guardian Contact Father's Cell Phone Mother's Cell Phone The Caretaker It is important that this person is always available Child's Health Caretaker First Last This is the person that will be handling the minor's health care decisions if or when the parent or legal guardian is not available Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Caretaker's Contact Caretaker's Cell Phone Minor (Child) *1 Form per Child Name of Child First Last The name of the child that is having their medical care handled. Date of Birth Minor (Child) Medical Information Does the Child have any known Allergies to Food or Drugs? Does the Child have any known Allergies to Food or Drugs? YesNo List Allergies Is there any Special Medication, Blood Type, or Pertinent Information the Medical Staff should know? Is there any Special Medication, Blood Type, or Pertinent Information the Medical Staff should know? YesNo Enter any Special Medications or other pertinent information If none leave blank Do you know the Year of the Child's Last Tetanus Shot? Do you know the Year of the Child's Last Tetanus Shot? YesNo Year of Child's Last Tetanus Shot? Year If you don't know just leave blank Insurance Information Insurance Company Name Policy Number Hospital Information Child's Primary Care Physician Primary Care Physician's Phone Number Child's Preferred Hospital Term of Relationship Has to have a set term. Recommended time-period is between 6 and 12 months Begins on End on Signature Date Day this form will be Signed Enter the Date when this form will be signed by the Parent or Legal Guardian Parent or Legal Guardian Signature Parent or Legal Guardian Signature Clear Please draw your signature. Print Name If the Person is not available to Electronically Sign below then click 'Save' and it can be signed after printing Witness Signature Witness Signature Clear Please draw your signature. Print Name If the Person is not available to Electronically Sign below then click 'Save' and it can be signed after printing Next Save Save and finish later
