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Back to Forms for 'Medical Consents & Releases'.




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




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