To whom it may concenrn,
The undersigned does hereby give permission for our (my) child to attend and participate in any and all Wednesday night activities sponsored by First Baptist Church of Iva, South Carolina.
We (I) authorize an adult, in whose care the minor 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 the minor under the general or special supervision and on the advice of any physician licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree to pay additional costs not covered in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. I further release First Baptist Church of Iva, from any further liability.
Sign and date bellow.