To Whom It May Concern:
The undersigned does hereby give permission for our (my) child to attend and participate in activities sponsored by the Highland Park Evangelical Free Church IMPACT Student Ministry.
We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examinations, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the 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.
The undersigned shall be liable and agrees 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 our (my) child to return home due to medical reasons or for disciplinary action, the undersigned shall assume all transportation costs.
The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated for this event, by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Highland Park Evangelical Free Church.