Please list any allergies (food, medication, etc.) that your child may have, or type "none"

Please list any physical conditions, special medications, or other health information of which we should be aware, or type "none"

My child has permission to receive any of the following that are selected according to package dosage:

I, (we) the parent or guardian of the singer named above, do hereby authorize and consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable and is to be rendered under the general or special supervision of any medical or emergency room staff licensed under the provisions of the Medical Practice Act. I (we) agree to accept responsibility for all costs incurred from the rendering of needed emergency services for my (our) child. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but it is given to provide consent to such care when the foregoing licensed physician in his/her best judgment deems it advisable. It is understood that the hospital shall attempt to contact the undersigned and the physician identified above if one is noted, prior to rendering treatment to the minor or dependent adult. However, treatment will not be withheld if the undersigned and/or the singer's physician cannot be reached. I (we) agree to save and hold the officers, employees, or agents of the Mountain Empire Children's Choral Academy and the medical care providers harmless from all liability, suits, or claims, of whatever nature or kind which might arise as a result of administering needed emergency care. I (we) hereby authorize the hospital to surrender physical custody of my (our) child to the individual who presented him/her for treatment upon completion of treatment if I (we) are not present at the time of discharge.