I sent one with my parents when they had DD for a few days. Here is the language I used. I am not in a legal profession specifically, but do insurance claims work and the language is similar to other authorizations and releases I have used. Hope this helps...
Parental Permission and Medical Consent
DD Name
Date of Birth
Home Address
Home Phone
I, *my Full name*, do hereby give my consent for my daughter, *DDs Full name*, to travel with *my Father's full name* and/or *my Mother's full name*. Further I authorize them, on my behalf, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by and is rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital, during all times that *my Daughter's full name* is in the presence of *my Father's full name* and/or *my Mother's full name*.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of *my Father's full name* and/or *my Mother's full name* to give specific consent to any and all such diagnosis, treatment or hospital care which the physician, in the exercise of his best judgment may deem advisable.
Health Insurance Information:
Company Name
Group Number
ID Number
Claims Address:
Company Name
P.O. Box
Dallas, TX 75226-0044
No known medical conditions. No known allergies. Blood type unknown at this time Mom is A+; Dad is O+. All immunizations current up to *age* year old preventative care visit.
X__________________________________________________
*My full name*, Mother and natural parent
