Parent/Guardian Authorization for

Emergency Treatment for a Minor Child

As the parent or legal guardian for _____________________________ whose date of

birth is ___________________, I hereby give my permission for Platinum Gymnastics

Staff Member in charge:____________________________________ to seek medical

attention for my child in the event of an emergency as follows:

Medical

X-ray examination

Anesthetic

Licensed Dentist

Licensed Hospital

Emergency Medical Attention

Whether diagnosis or treatment is rendered at the office of the physician or dentist, or

licensed hospital, I authorize the physician or dentist to call in any necessary consultants

at his/her discretion.

It is understood that this consent is given in advance of any specific diagnosis or

treatment being required, but is given to encourage those persons who have temporary

custody of the minor, and said physician or dentist to exercise his/her best judgment as to

the requirements of such diagnosis, medical, dental or surgical treatment.

This consent shall be come effective on the date signed below and remain in effect until

Aug 31, 2011, unless sooner revoked in writing, delivered to said physician or dentist or

said persons entrusted with the custody, care and control of said minor child.

Effective this Date: ______________________

Parent / Guardian of Minor Named Above ____________________________________

(Printed Name)

Parent / Guardian of Minor Named Above_____________________________________

(Signed Name)

Witness: __________________________________

List all know allergies: ____________________________________________________

List all previous injuries: __________________________________________________