I am (We are) the parents of the minor children ________________________________________________ (CHILDREN NAMES). I (We) temporarily, because of our absence, entrust ___________________________________________________________________ (CHILDREN NAMES) 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 ___________________________________________________ (CHILDREN NAMES). "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.