Medical Authorization

Parent/Guardian Name

First Name

Last Name

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of the organization to whom you give authority

Address of the organization to whom you give authority

Child's Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Child's Name

First Name

Last Name

Birth Date

MM

DD

YYYY

What are reasons to take this step?

Please list any medication instructions

Date on which the authorization will begin

First day of school

MM

DD

YYYY

Date on which the authorization will end

June 1, 2026

MM

DD

YYYY