We, the undersigned parents or legal guardian of the above student, do hereby consent to any x-ray
examination, anesthetic, medical or surgical diagnosis or treatment and hospital services that may be
rendered. It is understood that reasonable effort will be made to contact the parent/guardian and the doctor
listed above before any other physician is called by the school. It is understood that this consent is given in
advance of any specific diagnosis or treatment which might be required.
In addition I have read and understand the Emergency Authorization statement and give my full consent
to the terms found therein. Permission for photo copying of this health record is granted
Present Family Health Insurance Company