Consumer Closing Disclosure PDF Details

Engaging with the Consumer Closing Disclosure form reveals a vital protocol designed specifically for safeguarding minors during times of emergency when they cannot be accompanied by their parents or legal guardians. Emphasizing the necessity for prompt and efficient medical decision-making, this document entrusts a designated adult with the authority to oversee and arrange medical care for the child in question. Included within its contents are critical details concerning the minor's full legal name, home address, date of birth, gender, along with essential medical information such as the physician's contact details, medical insurer, known allergies, and current medical treatments. Moreover, it clearly outlines an authorization segment where the parent or legal guardian consents to allowing the designated adult to initiate general first aid, and in severe cases, authorize emergency medical procedures including surgery. This consent aims at ensuring the minor receives immediate care without the delay of attempting to contact legal guardians first, also binding the parents or guardians financially to the emergency medical expenses incurred. The form acts as a bridge, empowering caregivers with the legal backing to make medical decisions, thus underscoring its significance in preemptive healthcare planning for minors under temporary supervision.

Form NameConsumer Closing Disclosure
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesclosing disclosure, closing disclosures for nys, closing disclosure form template, closing disclosure forms

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This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible or practical to contact them. This form should be given to the trip leader or shown to the trip leader and then carried by the designated adult.


Full Legal Name: ___________________________________________________________________

Home Address: ____________________________________________________________________

Date of Birth:______________________________ Gender: Female___________Male___________


Physician’s Name and Location of Practice: __________________________________________________


Physician’s Phone # (if known): (____)________________

Medical Insurer/Health Plan: __________________________ Policy #: ______________________

Allergies to Medications: _____________________________________________________________

Allergies (Other): ___________________________________________________________________

Please note ALL conditions for which the child is currently receiving treatment:


Note any other significant medical information:



I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for _________________________________________ (hereafter “Designated Adult”) to

administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care.

It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

This authorization is effective through: ____________________. Signed this _____day of________, 20__.

Parent / Legal Guardian Signature: ________________________Printed Name: _____________________

Witness Signature: _____________________________________Printed Name:_____________________


Rev. July 2004

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