Medical Authorization for Minor

Temporary parental authorization for a caregiver — grandparent, family member, daycare, babysitter, or other trusted adult — to consent to medical care for a minor child when you are not present.

Important: This is a temporary parental authorization, not a Healthcare Surrogate Designation or healthcare power of attorney. Parental rights are not transferred. This is self-help document preparation, not legal advice. We are not attorneys.

Document language

Choose what language(s) you want the final PDF in.

English only $9.99 One PDF in English Solo español $9.99 One PDF in Spanish Best value Bilingual pack $14.99 Two PDFs — English + Spanish

Parent or legal guardian (you, the signer)

The parent or legal guardian signs this document in front of the notary. Your signature is what gets notarized.

Full legal name Phone number Relationship to minor Government ID type ID number ID issuer Street address Apartment / Unit (optional) City State ZIP code

The minor child

Minor's full legal name Date of birth Blood type (if known) Known allergies (optional) Current medications (optional) Known medical conditions (optional)

Authorized caregiver

The adult you are authorizing to make medical decisions for the minor when you are not present.

Caregiver's full legal name Caregiver's phone number Relationship to minor Caregiver's street address Apartment / Unit (optional) City State ZIP code

Scope of authorization

What medical decisions is the caregiver authorized to make?

Scope

Validity period

When does this authorization start and end?

Valid from Valid through Date of statement State of execution (optional) County of execution (optional)

Primary care & insurance (optional)

Helpful for providers. All fields are optional.

Pediatrician name Pediatrician phone Insurance carrier Policy / group number Member ID

Additional instructions (optional)

Your contact

Your name (for delivery) Email (we send your document here) Phone (we may contact you about your order)

Before signing

Bring these to your signing

01

Your government-issued photo ID

Driver's license, passport, or state ID — required for the notarization.
02

Your child's medical info

Allergies, medications, conditions, blood type if known. Many ER intake forms ask for this — having it in the document saves time in a crisis.
03

The caregiver's exact contact info

Full legal name (matching their ID), phone, address. The caregiver doesn't need to sign — only the parent signs and is notarized.
04

Clear start and end dates

Most providers want a defined validity period. A trip, a school year, a summer camp — pick a window that matches the need.

I understand this service does not provide legal advice. The information I provided is true and accurate. This is a temporary parental authorization and is NOT a Healthcare Surrogate Designation or healthcare power of attorney. YYMA Notary Services LLC is not an attorney and is not a law firm. I have read and accept the terms.

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