Authorization for medical treatment of a child AboutAuthorization to have your child medically treated while away.PriceKsh 1,750 Step 1 of 6 16% What is the effective date of this Authorization?*Format: 23rd day of December 2018 Who is issuing this authorization?*First nameLast NameAddress i.e. the legal guardian or the parents. Who is the minor(s) in subject to this authorization?*First NameLast Name To whom is this authorization and consent granted* First Last Referred to as the designated guardian. What is the termination date of this Authorization?*Format Example: 18th February 2020 Select the payment Mode*MpesaAirtel MoneyCurrently we only support Mpesa and Airtel Money. Send M-PESA Ksh. 1,750.00 to Buy Goods and Services Till number 239230. Submit the Confirmation Code below. Go to M-PESA on your phone Select Buy Goods and Services option Enter Till no. 239230 Enter the Amount Ksh. 1,750 Enter your M-PESA PIN and Send You will receive a confirmation SMS from M-PESA with a Confirmation Code After you receive the confirmation SMS, enter your phone number and the Confirmation Code Click on Complete Send Airtel Money Ksh. 1,750.00 to nick-name Uwakili. Submit the Transaction ID below. Go to Airtel Money option on your phone Select Send Money Option Select Enter Nick-Name Option Type the name Uwakili Enter the Amount Ksh. 1,750.00 Confirm Amount and Nickname Enter your PIN and Send You will receive a confirmation SMS from Airtel Money with a Transaction ID After you receive the confirmation SMS, enter your phone number and the Transaction ID Click on Complete Phone number*Input phone number in the following format: 2547xxxxxxxx, where x refers to your mobile number.Transaction code*This is the code you receive after successfully sending money. This iframe contains the logic required to handle AJAX powered Gravity Forms.