To whom it may concern:
The undersigned does hereby request permission for our child to attend and participate in activites sponsored by Our Lady of Lourdes Catholic Parish.
We authorize any designated adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under general or special supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the medical staff of a Licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for your child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.
Medical consent forms will be used only as needed. Every effort will be made to first notify the parent, guardian or emergency contact prior to the use of the medical consent form.