TO WHOM IT MAY CONCERN:
As a parent and/or guardian, I do herewith authorize the treatement by a qualified and licensed medical doctor of the following minor in the event of a medical emergency which, in the opinion of the attending phsycian, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. The authirity is granted only after a reasonable effort has been made to reach me.

This release form is completed and signed of my own free will with sole purpose of authorizing medical treatment under emergency circumstances in my absence.