Medical Treatment Auth Form - Tucson Youth Music Center

Medical Treatment Authorization Form

PARENTS AND GUARDIANS: Please complete this form for each child you are registering.

This form grants temporary authority to the Tucson Youth Music Center and its representatives to arrange for and authorize emergency medical care for a minor in the event that minor is not accompanied by parents or legal guardians or other person(s) designated by the parents and it is not feasible or practical to contact any of them in a timely fashion.
Minor Full Legal Name*
First Last
Information For Medical Treatment
Physician’s Name and Location of Practice:*

Physician’s Phone # (if known)
Medical Insurer/Health Plan

Policy #

Allergies to Medications

Allergies (Other)

Please note all conditions for which the child is currently receiving treatment
Please note any other significant medical information
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
Today's Date*
Signature*
Printed Name*
First Last
Section End
Phone
This field is for validation purposes and should be left unchanged.

Medical Treatment Authorization Form

PARENTS AND GUARDIANS: Please complete this form for each child you are registering.

Information For Medical Treatment

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

Section End

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