Authorization for Medical and/or Surgical Treatment for a minor during any Event of BSA Troop 272, Olivet Baptist Church, Lansing, Michigan

December 31, 2005 - December 31, 2006

I/We, ____________________________, the undersigned parent(s) and/or legal guardians of ____________________________, do hereby consent to and authorize any accredited hospital and its medical staff to administer and perform any emergency medical and/or surgical treatment deemed necessary in the judgement of the treating physician. I/We also authorize release of information for insurance purposes and payment directly to the hospital. We understand that BSA Troop 272, Olivet Baptist Church, Lansing, Michigan and it's staff and sponsors will not be held responsible/liable for any personal injury which may occur during the designated days of the event. We also understand that the owners (and any other members of the organization) of the location at which we may be (i.e. campground, lodge, amusement park, etc.) will not be held responsible/liable for any accidental personal injury which may occur on it's premises.

____________________________________	____________________________
Signature of parent/legal guardian	Date

Please list two (2) emergency contact names and phone numbers where a parent, relative, or responsible family friend can be reached in the event of an emergency.)

(1) _______________________________________________________________

(2) _______________________________________________________________