Part II:  To Grant Consent

I hereby give consent for the following medical care providers and local hospital to be called:

Physician _______________________________________Phone Number (with area code) ____________

Dentist _________________________________________Phone Number (with area code) ____________

Medical Specialist ________________________________ Phone Number (with area code) ____________

Local Hospital ___________________________________ Emergency Room Phone __________________

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctors, or, in the event the designated perferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Facts concerning the child's medical history, including allergies, medications being taken, and any physical impairments to which a physician should be alerted:

Date _______________ Signature of Parent or Guardian _______________________________________

Street Address_________________________________ City, State and Zip ________________________