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MEDICAL & DENTAL RELEASE/CONSENT AUTHORIZATION FOR A MINOR I, [PARENT_NAME], certify that I am the parent/legal guardian of the minor child(ren) listed below, and as such, I hereby convey temporary authority to the below designated adult(s) for the sole purpose of obtaining or arranging any emergency medical or dental care for the minor child(ren) as may be deemed necessary for the well-being of my child(ren), when not accompanied by a parent/legal guardian or should either parent/legal guardian be unreachable by telephone. THEREFORE, | hereby approve and empower the below listed individuals with the authority to arrange and/or consent for any and all emergency medical/dental care and treatment of my child(ren) in my absence, [SIGNATURE_PARENT LEGAL GUARDIAN] [DOCUMENT _DATE_SIGNED] (Signature Perent/Legal Guardian) (Date) PARENT_NAME} [PARENT_PRIMARY_PHONE] (Print or Type Name of Parent/Legal Guardian) (Home/Work Number) [RELATIONSHIP_TO_CHILD] [PARENT_ALTERNATE_PHONE] (Relationship to Child/ren) (Cell Number) Page 1 INDIVIDUALS AUTHORIZED TO ARRANGE/CONSENT FOR EMERGENCY MEDICAL/DENTAL CARE: [CHILD_CARE PROVIDER. NAME. 1] (Name) {HOME_OR_WORK_TELEPHONE_1] (Home/Work Number) [RELATIONSHIP_TO_MINOR_ CHILD 1} (Relationship to Minor Child) [CELL_NUMBER_1] (Cell Number) [CHILD_CARE_ PROVIDER. NAME 2] (Name) {HOME_OR_WORK_TELEPHONE_2] (Home/Work Number) [RELATIONSHIP_TO_MINOR_CHILD 2} (Relationship to Minor Child) [CELL_NUMBER.2] (Cell Number) [CONTACT_NAME_1) (Name) [CONTACT_PRIMARY_PHONE_1] (Home/Work Number) [CONTACT_RELATIONSHIP_1] (Relationship to Minor Child) [CONTACT_CELL_PHONE_1] (Cell Number) [CONTACT_NAME_2] (Name) ICONTACT_ PRIMARY _PHONE 2] (Home/Work Number) [CONTACT_RELATIONSHIP_2] (Relationship to Minor Child) ICONTACT_CELL_PHONE 2, (Cell Number) Page 2 MINOR CHILD(REN) Child’s Name: [MINOR_CHILD_NAME_1] Address: [MINOR_CHILD_ADDRESS_1] [MINOR_CHILD_CITY_1] [MINOR_CHILD_STATE_1] [MINOR_CHILD_ZIP_1] ‘Telephone Number: [MINOR_CHILD_TELEPHONE NUMBER _1] Date of Birth: [MINOR_CHILD_DATE_OF_BIRTH_1] Parent/Legal Guardian: [PARENT NAME_1] Address: [PARENT_ADDRESS_1] [PARENT_CITY_1], [PARENT_STATE_1] [PARENT_ZIP_1] Home/Work Telephone: [PARENT_PRIMARY_PHONE._1] Cell Telephone: [PARENT_ALTERNATE_PHONE_1] Allergies: [LIST ANY KNOWN ALLERGIES 1 Medical Conditions: [LIST_ANY KNOWN MEDICAL CONDITIONS 1 Current Medications: [LIST_CURRENT_MEDICATION_NAME._1] Child’s Name: [MINOR_CHILD_NAME 2] Address: [MINOR CHILD_ADDRESS 2] ‘Telephone Number: [MINOR_CHILD_TELEPHONE_NUMBER 2 Date of Birth: [MINOR_CHILD_DATE_OF_BIRTH_2] Parent/Legal Guardian: [PARENT_NAME_2] Address: [PARENT_ADDRESS_2] [PARENT_CITY_2], [PARENT_STATE_2] [PARENT _ZIP_2] Home/Work Telephone: [PARENT_PRIMARY_PHONE_2] Cell Telephone: [PARENT_ALTERNATE PHONE 2] Allergies: [LIST_ANY_KNOWN_ALLERGIES 2] Medical Conditions: [LIST_ANY_KNOWN_ MEDICAL CONDITIONS 2] Current Medications: [LIST_CURRENT_MEDICATION_NAME_ 2] Page 3