Dupont Hospital, Fort Wayne Indiana
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Parental Consent Form

If you’re traveling and have to leave your children in the care of someone else, be sure they’re protected. Always leave written authorization so your children can receive emergency medical treatment, if needed. For your convenience, Dupont Hospital has provided a link for a downloadable Parental Consent Form. Simply download the form below, fill it out, and leave it with your children’s caregiver. You’ll need a separate, dated form for each child each time you leave town.

(To view the Parental Consent Form, you'll need the free Adobe Acrobat Reader.)

Click to view and print the Parental Consent Form.

 
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