I, The undersigned parents or guardian of________________________, a minor hereby authorize adult workers with the youth of the above

named church to consent to any examination, x-ray, anesthetic, medical

or surgical diagnosis or treatment  and hospital care which rendered

under supervision of any physician or surgeon licensed  under the

provisions of the Medical Practice Act on the medical staff of a licensed

hospital, whether such diagnose  or treatment is rendered at the office of

said physician or at said hospital.

Further, as part or guardian of the minor named above, I do hereby

expressly consent that my son/daughter may receive emergency medical

treatment from any physicians, hospital, or other medical center without

the necessity of first notify  me, and do further agree to  hold blameless

any physician, hospital or other medical center for rendering such services.