PE 2 – Semester 2

minor/student, I hereby authorize the principal or his/her designee, into whose care the aforementioned minor student has been entrusted, to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis, treatment and/or hospital care to be rendered to said minor/student upon the advice of any licensed physician and/or dentist. I understand that this authorization is given in advance of any required care and provides authority and power to the aforementioned agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which a licensed physician or dentist may deem necessary. This authorization shall remain effective for the full summer school program unless revoked in writing and delivered to said agent(s). I understand that the Summer School, its employees and its Board assume no liability of any nature in relation to the transportation or treatment of the said minor/student. I further understand that all costs of paramedic transportation, hospitalization and any examination, X-ray or treatment provided in relation to this authorization shall be my responsibility.