I, (fill in name)blanks hereby authorize adult workers at Choices Afterschool Program at the Military Street Baptist Church to give my child (fill in child's name)blank over-the-counter medicine (i.e. Tylenol/Ibuprofen) on an as needed basis. Yes No In case a parent/guardian or the emergency contact cannot be reached: I authorize adult workers to secure medical or dental care; which may include but not limited to ambulance, x-rays, examination, anesthetic, medical or dental diagnosis in the event of illness or injury while under the supervision of the staff and volunteers of the Choices Program. I shall pay for all such expenses and will in no way hold Adopt-A-Block of Aroostook, Military Street Baptist Church, or its representatives responsible for any financial obligation. Yes No Signature