I hereby empower JTI, JCCNS and/or Temple Partner staff to act for me in accordance with their best judgment in case of emergency. I hereby authorize the physician selected by a JTI/JCCNS staff or Temple Partner staff person to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child named above. I have also read and signed the Code of Conduct and witnessed my child signing it. *