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