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Confidential Rev. July 2004
Medical Treatment Authorization Form
This form grants temporary authority to a designated adult to provideand arrange for medical care for a
minor in the event of an emergency, where the minor is not accompanied by either parents or legal
guardians, andit may not be feasible or practical to contact them. This form should be given to the trip
leader or shown to the trip leader and then carried by the designated adult.
Full Legal Name: ___________________________________________________________________
Home Address: ____________________________________________________________________
Date of Birth:______________________________Gender: Female___________Male___________
Information for Medical Treatment
Physician’s Name and Location of Practice: __________________________________________________
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