Ron Gercke, Coach
We/I,
_________________________________________, the
lawful parents of__________________________________, hereby appoint RON
GERCKE, swim coach for AFOX, to be a lawful attonery-in-fact (agent) to perform
any and all acts We/I might perform if We/I were present for the following
Purpose:
To
authorize any and all emergency medical and hospital care treatment, including
major surgery, deemed necesssary by the personnel of the closest medical
facility or any physician, for the health and well being of our
child__________________________________________.
We/I
give this authorization in advance of any care or treatment being required in
order to provide authority for my attonery –in-fact (agent) to give specific
consent to any and all care treatment that might be necessary in my
absence. It is understood that a valid
dependent medical card and/or any other form that may be required by our
medical insurance company, will be provided for ___________________________for
the purpose of filing a medical emergency claim.
MEDICAL GROUP OR PLAN NAME:
Primary Insured:
__________________________________________
Plan/Group Number:
_______________________________________
Parents Signatures:
__________________________________
__________________________________
Date:
_____________