Medical Authorization for Minors


I, ___________________________________________________, the parent or legal guardian 
                (parent or legal guardian name)

of: __________________________________________________, a minor, do hearby authorize
                (minor’s legal name)

any one or more of ________________________________________________________, or
                                        (legal name)

____________________________________, or _____________________________________
        (legal name)                                            (legal name)

in my absence or incapacitation to consent to any X-ray examination
and anesthetic, medical or surgical diagnosis or treatment and medical
care which is deemed advisable by and is to be rendered under the
general or special supervision of any physician or surgeon licensed
under the provisions of the Medical Practice Act on the medical staff
of any hospital whether or not such diagnosis or treatment is rendered
at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any
specific diagnosis, treatment or hospital care being required but is
given to provide authority and power on the part of the aforesaid
agents to give specific consent to any and all such diagnosis,
treatment or hospital care which aforementioned physician in the
exercise of his or her best judgement may deem advisable.

I hereby authorize any hospital which has provided treatment to the
above named minor to surrender physical custody of such minor to the
above named agents upon completion of treatment.

These authorizations shall remain in effective until 

_____________________________,19_____.


___________________          _____________________________________________________
        (date)                                  (parent or legal guardian’s signature)

Please note any specific health plan or insurance information such as
membership or policy numbers on the back of this form.

Copies of this form, duly executed, should be in possession of the
named minor; at least one adult named in this document and present at
the event; and the parent or legal guardian executing the Medical
Authorization.

The SCA requires minor participants (i.e. those having to have
waivers) whose parents or legal guardians are not present at the event
to have a valid Medical Authorization Form. The SCA recommends use of
the Medical Authorization for all minor attendees.