Name of Minor_________________________________________________________________
Birthdate_____________________________________________________________________
List allergies and/or medical conditions:_____________________________________________
_____________________________________________________________________________
_____________________________________attach a separate sheet if more space is required.

I/We, being the parent(s) or legal guardian(s) of the above named minor, do hereby appoint: Cathie E. Peck of Mount Markham High School, West Winfield, NY 13491, (315) 822-6343 to act in my/our behalf in authorizing unexpected medical, dental, surgical care and hospitalization for the above named minor during the period of my/our absence, from Tuesday, October 3, 2000 to and including Thursday, December 14, 2000.

This document shall be presented to a physician, dentist or appropriate hospital representative at such time as unexpected medical, dental, surgical care or hospitalization may be required.

1. Parent/Guardian Signature_____________________________________________________
Address and Date______________________________________________________________

2. Parent/Guardian Signature_____________________________________________________
Address and Date______________________________________________________________

1. Witness Signature_____________________________________________________
Address and Date______________________________________________________________

2. Witness Signature_____________________________________________________
Address and Date______________________________________________________________

Please list phone number(s) and approximate times where you may be reached during this time.
_____________________________________________________________________________
_____________________________________________________________________________

Hospitalization Coverage for the above named minor:
Insurance Co. or Government Program______________________________________________
I D or Contract Number__________________________________________________________
Family Physician_______________________________________________________________
Phone Number_________________________________________________________________

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