I certify that I am the parent or legal guardian of the minors children listed below, and as such, I hereby convey temporary authority to the adults designated below for the sole purpose of obtaining any emergency medical care for my minor children that is recommended by a licensed healthcare provider to whom the children are presented for treatment subject to the limitations provided below (if any) and as may be deemed necessary for the well-being of my children when not accompanied by a parent/legal guardian, or should either parent/legal guardian be unreachable by telephone.
BE IT FURTHER KNOWN THAT I hereby releases any licensed health care provider providing medical care to the minor children listed below in reliance of this form from liability relating to such provider's acceptance of my substitute care giver's consent.
THEREFORE, I hereby approve and empower the individuals listed below with the authority to arrange and/or consent to any and all emergency medical care treatment of my children in my absence. This consent shall remain in effect until it is revoked by notifying the appropriate medical, mental healthcare and insurance providers, in writing, as well as the agent(s) named below that I wish to revoke it.