I/We, the above listed parent(s), or guardian(s), with legal custody of the above named child, with above cited date of birth, a student at Brookhaven Treatment and Learning Center, hereby appoint as agent with full power in our name, Brookhaven Treatment and Learning Center to give or withhold consent for routine and emergency medical care.
 
I understand that a Brookhaven Treatment and Learning Center representative will attempt to notify me at the above listed telephone number(s) before making any medical decisions, but that if the emergency circumstances warrant immediate medical intervention, or if I cannot be reached, Brookhaven Treatment and Learning Center is hereby appointed our/my agent to consent to emergency medical care.  I/We agree to hold harmless the medical personnel and institutions who perform the indicated medical procedures insofar as they base their authority to proceed on the consent of Brookhaven Treatment and Learning Center.