Authorization for Emergency Medical Treatment

Name:*

Adult or Minor*

Parent or Guardian Name: (if applicable)

Treatment Authorization

I do hereby give permission to the Muscatine Police Department and/or it's agents in the supervision or control of me as a Muscatine Police Explorer, to authorize emergency medical care for me if I am unable to make such decisions for myself due to injury.

Parental Authorization (if applicable)

I do hereby give permission to the Muscatine Police Department and/or it's agents in the supervision or control of my minor child, who is a Muscatine Police Explorer, to authorize emergency medical care for said child if I am not present and am unable to make such decisions for the child.

I agree with the above statement.*

Yes

No

Explorer Signature:___________________________________________

Parent/Guardian:_____________________________________________

Date:______________________________________________________