Instructions

Instructions For Consent Of Parent Or Guardian For Medical Treatment Of Minor Child

a. Name of Parent or Legal Guardian. Print your legal name (as it appears on your driver's license or other legal documents) as the parent or legal guardian of the child. Be sure to include your telephone number -- preferably a cellular telephone that you intend to carry while the custodian is baby-sitting.

b. Name of Custodian. Print the legal name of the person who will be watching or "baby-sitting" your minor child. This person must be at least 18 years of age or older in order to be able to contract for medical care services for the child. Since many times a baby-sitter is much younger than this, you should ask the baby-sitter's parents if they would be willing to act as Custodian and make medical decisions if you cannot be reached in a timely fashion. Insert the adult's name as the Custodian.

c. Name and DOB of Child. Print the legal name of the child and the child's date of birth for identification purposes. If you have more than one child, have one of these documents signed and notarized for each child.

d. Expiration Date. This is a powerful document that grants decision-making ability to another person over your child. For that reason, we automatically have this form expire after six months. If you intend to use the Custodian for a longer period of time, then insert a different date (perhaps one year from the signing date).

3. Limitations on Consent. If you have religious or other reasons to limit this consent, please note that information in the space provided. Otherwise, write "N/A."

4. Special Instructions to Custodian. If the child has allergies, or there are other considerations for medical staff to be aware of, write that information in the space provided. Otherwise, write "N/A."

Notary Acknowledgment. Even though Arizona (and most other states) does not specifically mention this type of document, it is intended to comply with A.R.S. Section 36-3221 (Health Care Power of Attorney). As such, it needs to be notarized in order to be recognized as a legal document.

Give Original to Custodian. The Custodian needs to have the original in his or her possession in the event of a medical emergency.

If you have any additional questions about this document, please contact attorney Paul E. Deloughery at the Deloughery Law Office, P.C. at 602-443-4888 or paul@delougherylaw.com.