As parent or legal guardian of the minor child named above, I hereby authorize the group leaders and/or those parents acting as activity supervisors to act as my agents to consent to medical, surgical or dental examination and/or treatment for the minor child. In case of emergency, I hereby authorize treatment and/or care at any hospital or urgent care facility. If there is an emergency and I cannot be reached, please contact the above emergency contact(s). I give permission to the physician selected by Creekside Church to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with Creekside Church staff and/or adult volunteers. In addition, Creekside Church has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.