CHILD’S MEDICAL CARE AUTHORIZATION
I, ____________________________________, the
____________ (Father/Mother) of
___________________________________________ (Child),
who is at present in the custodial care of
________________________________________________________ (Name/Names) pending _____ (His/Her) formal adoption, do hereby
lawfully authorize _____________________________________________________ (Name) to make any arrangements necessary
for the appropriate medical or surgical care of the above-named child and
confer all required consents in connection therewith to the above-named
__________________________________ (Name).
This medical care authorization will cease to be
effective at that point in time when
_______________________________ (Child) is permanently released from the
custodial care of ____________________________________________ (Name).
Dated: ______________
________________________________________
Signature of Parent
