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All minors (under 18) attending the 1999 LPA National Conference July 2-10 without their parents or normal legal guardian must have a temporary guardian designated for the week of the conference. The following must be filled out by the parents of such an unaccompanied minor who is attending the 1998 LPA National Conference. Child's Name DOB _______________________________ SS # _____________________________ Insurance Carrier ___________________________ Policy # _______________ Group # _________ I give permission for my child (Name) _________________________________ to receive full medical treatment in the event of an emergency. Exceptions (if any) I authorize (name) __________________________________________________ to be the legal guardian for my minor child during the week of July 2-10 in Portland Oregon. Signature _________________________________________ Date ______ Parent's Name Address ___________________________________________ City _________________ State _______ Zip _____ Home phone: (____) __________ Work phone: (____) __________ Name of guardian - must be over 21 Address ___________________________________________ City __________________ State _______ Zip _____ Signature of guardian Allergies ______________________________________ Current Medications _____________________________ Other medical needs |