Medical Treatment Authorization

(Simple parent-to-parent)

Player's name:__________________________________________

Agent Parent:___________________________________________

Times/dates effective: _____________________________________


In my/our absence, and during the times/dates effective listed above, I/we authorize the Agent Parent named above to act in my/our stead in regards to all matters, including medical treatment decisions, affecting my/our child, the Player named above. To that effect. I/we release and hold harmless the Agent Parent from an claims, losses, liabilities, and damages associated with this grant of representation.

Signature of Parent: ________________________ Date:_________

Signature of Parent: ________________________ Date:_________