I hereby authorize the (SUPERVISOR/MANAGER/PASTOR/CAMP DIRECTOR) and his/her officers, agents,
servants, or employees that are 18 years of age or older, who supervise the activities at this (CAMP, CHURCH,
SCHOOL, ETC.) into whose care my child has been entrusted, to consent to needed or necessary medical care or dental care, or both, for my child.

The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic,
medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice
of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also
extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist
licensed under the Dental Practice Act for my child.

I further authorize the (SUPERVISOR/MANAGER/PASTOR/CAMP DIRECTOR) and his/her officers, agents,
servants, or employees that are 18 years of age or older, who supervise the activities at this (CAMP, CHURCH,
SCHOOL, ETC.) to receive physical custody of my child, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the (SUPERVISOR/MANAGER/PASTOR/CAMP DIRECTOR) and his/her officers, agents, servants, or employees that are 18 years of age or older who supervise the activities at this (CAMP, CHURCH, SCHOOL, ETC.).

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care
being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in
the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.

As parent or legal guardian of my child, I am responsible for the health care decisions of my child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my child is legally sufficient and that no consent from any other person is required by law.

The parent/guardian of youth(s) listed above will be contacted As Soon As Possible, but this may come after seeking medical attention in some serious cases.