The undersigned does hereby give permission for our (my) child,

We (I) authorize an adult, in whose care my child has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to my child under the special or general supervision of any licensed physician or dentist, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with any services rendered to the aforementioned minor pursuant to this authorization, including transportation costs, if any.

The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Wiley Association of Youth.

Father's Name
Mother's Name
Legal Guardian