Form KDOC-0092 "Consent to Medical Care - Parent" - Kansas

What Is Form KDOC-0092?

This is a legal form that was released by the Kansas Department of Corrections - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2006;
  • The latest edition provided by the Kansas Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form KDOC-0092 by clicking the link below or browse more documents and templates provided by the Kansas Department of Corrections.

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Download Form KDOC-0092 "Consent to Medical Care - Parent" - Kansas

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STATE OF KANSAS
KDOC
CONSENT TO MEDICAL CARE
I, _____________________________________________________parent or legal custodian of
__________________________, born (month, day, year)_______________________________,
do hereby consent to any medical or surgical care and the administration of anesthesia
determined by a physician to be necessary for the welfare of _________________________
while said juvenile is under the care, custody and control of the Secretary of the Kansas
Department of Corrections.
____________________________________
Signature of Parent or Legal Guardian
State of ________________________
County of ______________________
Now on this ______________ day of ________________, 20 ___, before me, a Notary Public, in
and for the aforesaid state, personally appeared the person who has signed this instrument in
writing, and such person has, in my presence, duly acknowledged the execution and signing of
the same to be his/her voluntary act and deed.
____________________________________
Notary Public
My commission expires ________________.
Your signature is acknowledgement that you have read and fully understand the provisions of this Consent Form.
If you do not understand any part of this form ask the person requesting your signature to provide clarification.
State of Kansas
Page 1 of 2
Kansas Department of Corrections
Form KDOC-0092
Rev. May 2006
STATE OF KANSAS
KDOC
CONSENT TO MEDICAL CARE
I, _____________________________________________________parent or legal custodian of
__________________________, born (month, day, year)_______________________________,
do hereby consent to any medical or surgical care and the administration of anesthesia
determined by a physician to be necessary for the welfare of _________________________
while said juvenile is under the care, custody and control of the Secretary of the Kansas
Department of Corrections.
____________________________________
Signature of Parent or Legal Guardian
State of ________________________
County of ______________________
Now on this ______________ day of ________________, 20 ___, before me, a Notary Public, in
and for the aforesaid state, personally appeared the person who has signed this instrument in
writing, and such person has, in my presence, duly acknowledged the execution and signing of
the same to be his/her voluntary act and deed.
____________________________________
Notary Public
My commission expires ________________.
Your signature is acknowledgement that you have read and fully understand the provisions of this Consent Form.
If you do not understand any part of this form ask the person requesting your signature to provide clarification.
State of Kansas
Page 1 of 2
Kansas Department of Corrections
Form KDOC-0092
Rev. May 2006
Whenever any juvenile has been placed by the Secretary of the Kansas Department of
Corrections or by any court of competent jurisdiction in a licensed foster care home, or a home
approved by the Department of Health and Environment and Department of Children and
Families as meeting licensing standards of a foster care home, and such juvenile needs medical
or surgical care determined by a physician to be necessary for the welfare of such juvenile,
consent to such care by the juvenile 's parent or legal guardian shall be deemed to have been
given if there has been given a consent to medical and surgical care by the terms of a written
order of a court of competent jurisdiction or if there has been a consent form signed by a parent
or other legal guardian of such juvenile and acknowledged before a notary public or other
persons authorized by law to administer oaths.
The Secretary of the Kansas Department of Corrections or such Secretary’s designee is
authorized to sign the consent form as legal guardian of any juvenile committed to the custody of
the Secretary or when authorized by order of a court of competent jurisdiction.
State of Kansas
Page 2 of 2
Kansas Department of Corrections
Form KDOC-0092
Rev. May 2006
Page of 2