I, __________________________, being the mother of _________________________, a minor child, do hereby authorize __________________________________ of __________________, _______________, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor child under the general and/or special supervision and upon the advice of a physician and/or surgeon licensed to practice medicine in any state of the United States, or to consent to any X-ray, examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to said minor child by a dentist licensed to practice dentistry in any state of the United States.
I direct any hospital, medical staff, or physician treating said minor child to give to _____________________ the same priority in visitations that would be extended to me as said minor child’s mother in the event that said minor child is a patient in any hospital or other health care facility.
I authorize any school, day care, or similar institution providing services to me for my minor child, _______________, to release any and all records, information, or documentation relating to said minor child to _________________________.
I further direct such school, day care, or institution to accept ________________’s signature or consent in lieu of mine with regard to parental authorization to enable said minor child to take part in outside or in-school activities or day care activities, to sign for report cards or similar notices, to provide notice of said minor child’s absence from school, and the like.
I further authorize these acts as the sole physical and legal custodian of said minor child under the laws of the State of _________________________.
In the event of emergency, I direct that the school, day care, or institution make a reasonable effort to contact _______________________________ and me immediately.
I further direct that in a medical emergency the school, day care, or other institution has my permission to send said minor child immediately to a hospital with a trauma center that is reasonably close to the place where such medical emergency took place.
I declare that any act lawfully done or authorized hereunder by _______________ shall be binding on myself, my heirs, legal and personal representatives, and assigns. I agree for myself, my heirs, and assigns to hold same harmless and indemnify all persons, hospitals, agencies, and/or institutions acting in reasonable reliance on the authority herein conferred.
IN WITNESS WHEREOF, I have hereunto signed my name this ____ day of _________________, 20__ at ______________________, ______________.
State of _______________
County of _____________
At ____________________________, __________________, on the ____ day of 20__, ___________________________ personally appeared before me. He/She acknowledged this instrument, by him/her sealed and subscribed, to be his/her free act and deed.