As the parent/Legal guardian of the child named on this form, I herby grant my permission for my child to participate in the discovery, youth or any other program conducted by Cornerstone Missionary Baptist Church of Reedsburg, WI ("Cornerstone Church"). I give permission for Cornerstone to photograph and electronically record (audio or video) my child as part of regular program activities, and allow any photos or video that include my child to be published. Further, I herby grant my permission for any adult stuff member of said program to seek and authorize emergency medical attention of behalf of my child in my absence, and herby release Cornerstone from any and all liability associated therewith.
I consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licenses under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment or hospital care by a dentist licenses under the Dental Practice Act for my child. I further agree to pay all charges associated with the dental, medical or hospital care and/or treatment.
As parent/Legal guardian of the child listed on this form, I am responsible for the health care decisions of my child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the dental, medical, or hospital care and/or treatment to be rendered to my child is legally sufficient and that no consent from any other person is required by law.