Temporary Guardianship/Permission Slip & Medical Treatment Authorization

Minor’s Information (please print):

Name: ______________________________________________________________________________

Permanent Address: _________________________________________________________________

Phone: _________________________________ Date of Birth: __________________________

Parent/Legal Guardian Information (this includes emergency contact information) (please print):

Parent 1/Guardian 1 Name: __________________________________________________________

Permanent Address: _________________________________________________________________

Home Phone: ____________________________Cell Phone: ________________________________

Work Phone: ____________________________Email: ________________________________

Parent 2/Guardian 2 Name: __________________________________________________________

Permanent Address: _________________________________________________________________

Home Phone: ____________________________Cell Phone: ________________________________

Work Phone: ____________________________Email: ________________________________

Temporary Guardian Information:

Name: ______________________________________________________________________________

Permanent Address: _________________________________________________________________

Phone: ______________________________________________

Relationship to Minor: _________________________________

Authorization/Consent of Parent(s)/Legal Guardian(s)

I affirm that the minor child named above is my child and that I have legal custody of that child.

I give my full authorization & consent for my child to travel with the temporary guardian listed above.

I give the temporary guardian permission to act in my place and make decisions pertaining to my child’s participation in the Company event known as _______________________________________.

I give the temporary guardian permission to authorize medical and/or dental care for my child, including but not limited to medical examinations, x-rays, test, anesthesia, surgical operations, hospital care, or other treatments that in the temporary guardian’s opinion are needed or useful for my child. Such medical treatment shall be provided under the supervision of a physician, surgeon, dentist, or other medical practitioner licensed to practice medicine in the United States.

This authorization shall cover the period from _______________________________________ to ___________________________________.

My child is covered by the following insurance information:

Insurance Company Name: _________________________________________________

Group Number: ______________________________ Policy Number: ________________

Member Identification Number: _________________________________________________

Parent 1’s/Guardian 1’s signature: ___________________________________ Date: _____________________

Parent 2’s/Guardian 2’s signature: ___________________________________ Date: _____________________

I solemnly affirm that I will assume full responsibility for the minor listed above during the time-period designated above. I agree to make necessary decisions and to provide consent for the minor as set forth in the authorization and consent above. I also agree to seek medical and/or dental care for this minor as set forth above.