Medical Treatment Information:
Name of Minor:	* required
Relationship to You:	* required
Name of Parent/Guardian:	* required
	(As a Parent/Guardian, I do hereby authorize the treatment by qualified and licensed Physician of any conditions which, in the opinion of the physician, is deemed necessary and appropriate. This authorization is granted only after a reasonable effort as been made to reach me.) Yes No
Emergency Phone Numbers:	* required
Family Physician:	* required
Physician Address:
Physician Phone:
	List of allergies, medication, contacts or other pertinent information:
	Health Insurance Co., Group and Policy or Contract Numbers:
Date:	* required