Prescreening Medical Authorization Letter

Sophia Green
456 Willow Street
Chicago, IL 60601
(555) 321-6547
January 1, 2024

To Whom It May Concern,

I, Sophia Green, hereby authorize David Black, residing at 789 Elm Avenue, Chicago, IL 60602, to act on my behalf in matters related to medical prescreening for my son, Ethan Lucas Green, born on September 20, 2014. This authorization includes granting permission to complete any required medical prescreening tests, provide medical history, and consent to routine diagnostic procedures as deemed necessary by licensed healthcare professionals.

Ethan Lucas Green has the following relevant medical information:

• Medical Conditions: Seasonal Allergies (requires antihistamines as needed)
• Allergies: None known

This authorization is valid from January 10, 2024, to January 20, 2024, and applies to all prescreening activities required for school enrollment, sports participation, or other programs requiring medical clearance.

For any questions or additional information, I can be contacted at (555) 321-6547.

Thank you for your cooperation in facilitating the necessary medical prescreening for Ethan Lucas Green.

Sincerely,
Sophia Green
[Signature]

Witness:
Olivia Carter
123 Pine Road
Chicago, IL 60603
(555) 987-4321
[Witness Signature]

Notary Public (if required):
Michael Johnson
[Notary Signature]
[Official Notary Seal]