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Authorization for Medical Treatment

I hereby authorize and give permission for the medical treatment of my child (name) ______________in the event o accident injury or sickness etc under the direction of persons listed below.

My name_______________________

Address___________________________

Home phone__________________

Mobile No:____________________

My insurance company number_________________

My policy number______________________

Our physician______________

Phone number________________________

Signature (parent/guardian)___________________date:___________________-

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