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AUTHORIZATION FOR DISCHARGE OF CHILD TO RELATIVE

AUTHORIZATION FOR DISCHARGE OF CHILD TO RELATIVE

 

Name of Hospital: ______________________________.

 

Name of Patient: _______________________________.

 

I, ____________________________________ (Name of Parent) authorize and request ______________________________________ (Name of Hospital) and/or the members of its staff to discharge my child, ____________________________ (Name of Child), born on __________ (Date), into the temporary care and custody of _______________

(Name and Address of Relative) whose relationship to the child is _________________ (Relationship), for the purpose of returning the child directly to me.

 

_______________________________                               _________________

Signature of Mother                                                               Date

 

_______________________________                               _________________

Signature of Father                                                                Date

 

Receipt of Child

 

I, _________________________________________ (Name of Relative) acknowledge receipt of the above-named child and intend, as instructed, to deliver the child directly into the care and custody of its natural mother or father.

 

_______________________________                               _________________

Signature                                                                               Date

 

_______________________________                               _________________

Witness                                                                                 Date



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