123 Marygold St. Anytown, CA 95928 (555) 555-1212
November 1, 2008
Attention [name of doctor, hospital or treatment center]:
I, Jennifer Jensen, authorize my daughter, Holli Hollister, of 123 Marigold St., to authorize any necessary emergency medical care on my behalf in the event that I am not able to do so.
This authorization is valid from November 1 through December 31 of 2008.