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I, ____________________________, parent/guardian of___________________________, Date of Birth _________ do hereby give permission and/or consent to Midget Gems Kid's Club Playgroup, to secure and authorize such emergency medical care and/or treatment as the above-named child might require while attending Midget Gems Kid's Club. I further authorize Midget Gems Kid's Club to administer emergency care/treatment as needed, until medical assistance is available.

I ____________________________ give consent for my child _____________________________

I also agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for said child as secured or authorized under this consent.

Doctor's Name ___________________________
Phone ___________________________
Preferred Hospital ___________________________
Hospital Address ___________________________
Signed ___________________________
Name ___________________________
Date ___________________________

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