Authorization for Medical Services

AUTHORIZATION FOR MEDICAL SERVICES

I ___________________, parent/legal guardian of ____________________ (name of child/ward), hereby designate Adrianna Duncan to act in my behalf to authorize such hospitalization, and/or medical attention as may be required in an emergency because of illness or injuries sustained by my child/ward while participating in any program offered by Catron Community Learning Center. I hereby assume financial responsibility for hospitalization, medical attention, and transportation provided. I request that I be contacted within a reasonable time in the event of illness or injury requiring medical services.  

Emergency Contact Name ________________________________________ 

Emergency Contact Phone Number _________________________________ 

Primary Care Physician  __________________________________________

Primary Care Phone Number ______________________________________ 

Specialist Name and Type ________________________________________

Specialist Phone Number _________________________________________

Child’s Health Insurance Provider __________________________________ 

Allergies ____________________________________________________

Known Medical Conditions ________________________________________

Medications ___________________________________________________

Parent or Legal Guardian Signature  ________________________________  

Parent or Legal Guardian Name (please print) ________________________