To whom it may concern:
The undersigned does hereby give permission for the above named minor, to attend and participate in activities sponsored by Grace Church from January 1, 2017 to December 31, 2017. I authorize an 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 the general or special supervision and advice of any physician or dentist licensed under the provisions 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. I understand, however, that every effort will be made to contact me in case of an emergency and, if possible, before any such medical treatment is administered. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Grace Church. I hereby release Grace Church from any responsibility other than normal supervision and care. In case of an accident, I will not hold Grace Church, or it's staff members, volunteers, management or officers liable unless guilty of negligence.