Nurse
Medical Power of Attorney
For Care of Minor Child
I affirm that I am the parent and/or legal guardian of the minor child
named below:
Child’s Name
Birth date
I hereby give consent to the Crow Creek Tribal School nursing staff to
seek and obtain routine medical, dental care and mental health services
for this child at the Fort Thompson Indian Health Care Center.
(Dormitory or school staff may take students under special
circumstances.)
In addition, I hereby give consent for the following adults to seek and
obtain routine medical and dental care for this child at Fort Thompson
Indian Health Center:
___________________________
__________________________
___________________________
__________________________
I understand that I or one of the above persons must accompany the
child each time medical or dental care is sought; otherwise care will not
be given until I (or the child’s other parent) am contacted and give
signed consent for care.
I further understand that this consent applies only to routine medical,
dental care and mental health services and that I must give additional
consent for more complicated or difficult procedures. Written consent is
not required for care during a serious emergency.
This consent expires at the end of the school year.
Signature
Relationship
Date
Witness
Title
Date