I am (We are) the parent(s) of the minor child _________________________ (CHILD NAME). I (We) temporarily, because of my (our) absence, entrust _________________________ (CHILD NAME) to the care of _________________________(name) whose address is ________________________________(street address), _____________________ (town), _____________________ (state).

I (We) authorize _______________________________ (name) to consent to medical care, or dental care, or both, for _________________________ (CHILD NAME). "Medical care" includes 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 licensed under the Medical Practice Act. "Dental care" includes X-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care by a dentist licensed under the Dental Practice Act.

Dated: ______________

___________________________

(Male Name)

___________________________

(Female Name)

Please Note: By law the signature of only one parent gives the authorization stated above.