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Macon County Habitat For Humanity, Inc.
56 West Palmer St., Franklin, NC 28734 |
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PARENTAL AUTHORIZATION FOR TREATMENT OF A MINOR CHILD |
I,___________________________________________________________, am
the parent or legal guardian having custody
of_____________________________________________, a minor child. As
such parent or legal guardian, I hereby authorize and
appoint_______________________________________, an adult in whose
care the minor child has been entrusted or a duly authorized agent
of Habitat for Humanity _________________________________, as my
agent to act for me with respect to my minor child and in my name in
any way I could act in person to make any and all decisions for me
with respect to my minor child,
________________________________________, concerning my minor
child's personal care, medical treatment, hospitalization, and
health care and to require, withhold or withdraw any type of medical
treatment or procedure, including X-ray examination, anesthetic,
medical or surgical diagnosis or treatment which may be rendered to
my minor child under the general or special supervision and on the
advice of any physician or surgeon licensed to practice in the state
in which treatment is sought. My agent shall have the same access to
my minor child's medical records that I have, including the right to
disclose the contents to others.
Witness__________________________________________1)
Parent or Guardian:_________________________
Witness:__________________________________________2)
Parent or Guardian:________________________
This PARENTAL AUTHORIZATION FOR TREATMENT OF A MINOR CHILD sworn to
and subscribed before me by_________________________,
and__________________________, the Parent(s) or Legal Guardian(s) of
_____________________________, a minor child, this____day of
___________, 20___
Notary Public:____________________________________
My commission expires:____________________________ |
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Construction
Activities | Re-Sale
Store Activities | Volunteer
Application |
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Standard
Waiver of Liability | Minor
Waiver of Liability |
Parental Treatment Authorization |
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© Copyright 2005. Macon
County Habitat For Humanity, Inc.
All rights reserved.
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