Appointment of agent for authorization for medical treatment

The undersigned parent/legal guardian of ___________________________________ hereby appoints ________________________________ as agent to authorize, in behalf of the undersigned, emergency medical/surgical treatment, including hospitalization, for the above named child which, in the opinion of any licensed physician, surgeon or hospital, is reasonably required or necessary  for the treatment or care of said child. Any physician, surgeon or hospital is authorized to rely upon any authorization for treatment signed by the above designated agent(s) to the same extent as if executed personally by the undersigned.
This appointment will remain valid and in full force and effect from __________ to __________
Our personal insurance carrier is ________________________ Policy # ___________________
The name of my daughter’s physician is _____________________________________________
He/She may be reached at (___)__________________         ________________________________
                                                         (phone)                                           (address)

Emergency information
____________________           _____________________________         ______________________
Father’s Name                                           Employer                                                                         Occupation
 _____________________________________________________________      (____)____________________
Mailing Address                                                                                                                          Home Telephone
______________________________________________________________      (____)___________________
City                                                   State                                  Zip                                             Business Telephone
_________________________            _________________________________     __________________________
Mother’s Name                                           Employer                                                                  Occupation
________________________________________________________________    (____)____________________
Mailing Address                                                                                                                              Home Telephone
________________________________________________________________     (____)____________________
City                                                   State                                  Zip                                                 Business Telephone
If parent/legal Guardian cannot be reached, you should call:
Name_________________________________________________ Relationship___________________________
Telephone Number (home) (____)__________________ (business)(___)____________________
____________________________________________________________________________
Signature of Parent/legal Guardian

(complete both sides of this form)

State of _________________________,____________________________County
Be it remembered, that on this _____day of ________,20__ before me, a Notary Public, in and for the County and State aforesaid, came__________________, to me personally known to be the same person who executed the foregoing instrument, and duly acknowledged the execution of the same. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal, the day and year last above written.
                                                                            _____________________________________
                                                                            Notary

My Commission expires:____________________

Emergency authorization
I hereby give my permission to authorize emergency medical treatment in the event of injury/illness to my daughter.  The health care provider is authorized to perform emergency medical services upon consent or the adult in charge from the Massachusetts Grand Assembly, International Order of the Rainbow for Girls.

Medical information
Check all conditions which apply to your daughter. Give specific cause of allergies and any special medical information that applies.

Allergies:                                                         Chronic/recurring illnesses:
Drugs_______________________                     Asthma_________________
Food________________________                    Diabetes________________
Hay Fever____________________                    Ear Infections___________
Insect Stings__________________                     Epilepsy________________
Poison Ivy____________________                     Heart__________________

Date of last:                                                       List any other current/recurring illness(es):
Tetanus toxoid immunization ______________    _______________________________
Health Exam ___________________________    _______________________________
Physical limitations: ___________________________________________________

Medical authorization
No Rainbow Girl should keep medication in her possession. All medications must be turned in to the adults in charge.
The adults in charge have my permission to dispense:
           1. My daughter’s medication (circle one) yes no
If yes, name of medication, dosage and schedule: _________________________________________________
______________________________________________________________________________________
            2. Non-Asprin substitute (such as Tylenol) to my daughter (circle one) Yes No
If yes, amount: ___________________________________________________________________________

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I certify that all the above information is correct.
____________________________________      ___________________________________
Signature of Parent/Guardian                                   Date

(complete both sides of this form)