Minor Authorization Form

Emergency Medical Condition (EMC) examination and/or Medical Treatment / Release of Information of a Minor Authorization Form This form grants authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible or practical to contact them.

| do hereby grant my authorization and consent for "Designated Adult") to administer an Emergency Medical Condition (EMC) examination and/or general treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care.

It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

Iagree that unless I give specific instructions otherwise, medical information regarding my child's diagnosis and treatment and account balance may be released to the natural mother, natural father, stepmother/stepfather, Designated Adult above, referring physicians, other physicians involved in the care of my child and my insurance company/companies.