This application has been completed and the information herein is correct as far as I am aware. The applicant has permission to take part in all PRPH activities, except as noted by the examining physician or me. I understand that every attempt will be made to contact me in the case of an emergency. In the event that I cannot be contacted, I give my consent to emergency x-rays, medical attention and treatments, surgery or dental care for the above mentioned participant. I also relieve PRPH, Inc. from any liability resulting from injury my child may sustain while participating in this program.