I hereby consent and authorize emergency medical treatment for my child(ren), listed on the application, in the event that I cannont be contacted. I understand that I am financially responsible for any expenses for medical care or transportation incurred on my child(ren)'s behalf. In the event of a serious injury, I understand that 911 will be called.

I hereby give St. Mary School System consent to use my child(ren)'s name(s) and/or photo(s) in news publications.

I hereby warrant to St. Mary School System and/or the School Age Child Care (SACC) program that I am entitled to legal custody and possession of my child and am authorized to sign this form. Additionally, I have read and understand this form. In consideration, I agree to hold harmless and indemnify the St. Mary School System and its employees against all injuries arising out of these arrangements.

Date:___________________________________________

Parent/Guardian Signature: _______________________________________