AUTHORIZATION
______________________ (Name of Parents) hereby authorize ______________________________
to obtain medical treatment for______________________ (Name of child) for the period
__________________________ to _______________________.
_________________________________
Signature of Parent
__________________________________
Signature of Parent
Sworn to before me this _____ day of __________, 20__
________________________________ (Notary Public)
Name of Child's Doctor: _______________________ Telephone Number: ____________________
nsurance company: _______________________________
Policy Number: __________________________ Insured: _________________________________
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