Sample Medical Permission Letter for Child

Posted in Permission Letters

A medical permission letter for a child is written in order to give an individual temporary legal authorization to make medical decisions for a child. People who have been given this permission form may take medical action as it is needed for the safety and care of the child stated on the letter.

Format and Content
The medical permission letter format for a child needs to have all valid doctor information and parent or legal guardian contact information. The date of effective legal authorization should also be stated as well as when the authorization expires. While a full letter describing the medical authorization given is helpful, it is not necessary for a medical permission letter to be binding. However, a full consent form should be attached to or provided below the letter.

This medical permission letter sample is for Robert Tyson, a teen who will be going on a trip to a youth camp with his school over the summer. This camp will have medical staff on site and all parents or legal guardians must consent to medical treatment being given if the need should arise. This letter is from Wanda Tyson, the child’s mother, to the youth camp staff at Bryson Gables.

Wanda Tyson
1783 10th Way
Conners Town, Georgia 77209
(738) 835-9023
September 7, 2013
Bryson Gables Youth Camp Staff
289 Bryson Gables Road
Georgia 77284
Dear Bryson Gables Youth Camp Staff Members,
I have completed the form provided by my child’s school, found below. However, I feel that additional information of my child’s medical records should be kept on file in case of an emergency. Please note, as stated in the form, that my child is highly allergic to bumble bees and also to poison ivy. I realize that many youth activities will be outdoors and this does concern me a little because of my son’s medical conditions.
I would be pleased if a youth worker could be assigned to him to keep a close eye on his safety and take full note of his medical history, if possible. Furthermore, I do realize that the Bryson Gables Youth Camp has an excellent history of medical treatment and has the most caring staff available, as I also attended your camp as a teen. Any response will be appreciated.
Thank you,
Wanda Tyson
Wanda Tyson

Medical Consent Form
To Whom It May Concern:
We, Wanda Tyson, and Matthew Tyson, parents of Robert Tyson hereby give our consent for necessary medical treatment to be provided to our child while attending the Bryson Gables Youth Camp.
Effective Date of Authorization:________________________.
Authorization Expiration Date:__________________________.
Medical Guardian/Parent Name:_________________________________________________________.
Parent Signature: _____________________________________________________________________.
Concerns or Allergies to be noticed by medical staff: My child is allergic to bees and poison ivy___________________________________________________________________________________________
*A copy of this document shall be considered effective as if it were the original.

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