Medical Treatment Auth Form - Tucson Youth Music Center

Medical Treatment Authorization Form

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
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Birth*
MM slash DD slash YYYY
Gender
- Female
- Male
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
MM slash DD slash YYYY
Signature
Printed Name
First Last
Name
This field is for validation purposes and should be left unchanged.