W
PARENTAL CONSENT AND AUTHORIZATION FOR MEDICAL TREATMENT
I (We) ______________________________ and ______________________________
the parent(s) and natural guardian(s) of ______________________________.
In the event we cannot be reached to obtain permission, hereby authorize The College of Wooster
and/or its authorized employee representative, the employer of said minor child, to act for us in an
emergency or other circumstance requiring any medical treatment or attention on behalf of our said
minor child without any further permission form the undersigned.
This consent and authorization shall include, but not be limited to, obtaining necessary hospital,
medical, surgical, dental, optical, pharmaceutical, and any related care for said minor child and to
sign any authorization therefore including admissions and/or discharges from any hospital or other
care facility.
We further authorize The College of Wooster and/or its authorized employee representative to
execute any and all other documents regarding the medical treatment of said minor child.
A photocopy of this consent shall be considered as effective and valid as the original.
Signed this ____ day of ________________, _________.
________________________________ Parent/Guardian
________________________________ Parent/Guardian
