Authorization of Consent to Treat Minor. I/We, the Parents listed below, are the parent(s) / guardians of the Student listed below, and as such do hereby authorize the School named below and its employees, contractors, and adult volunteers as our agent(s) (collectively, “School”) to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment or hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of, any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. I/we understand that this authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment or hospital care which the aforementioned physician in the exercise of best judgment may deem advisable. This authorization is given pursuant to the provisions of Chapter 32 of the Texas Family Code. This authorization shall remain effective for up to one year from the date of completion of this form, unless sooner revoked in writing delivered to said agent(s). I have read and agree to the section covering Authorization of Consent to Treat Minor Subject to the Release and Indemnification terms below, by my/our signature below, I/we consent to the School’s administration of Over-the-Counter (nonprescription) (“OTC”) medication. I/we understand and agree to the following (please initial each item below):
