As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed physician of any condition, which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me. I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.

I/we give my/our permission to the Roman Catholic Diocese of Grand Rapids, Michigan, (the Diocese) and all entities, representatives, employees, and agents operating under its authority to use, without prior notice, my name or my minor child’s name, city and state, and/or audio, video(s), photo(s), and/or any other likeness and to use statements made by or attributed to me or my child relating to the Diocese, without compensation, for web, social media, publicity or similar promotions for the Diocese. I waive my right to inspect or approve such publications, including any written copy that may be created in connection therewith. I/we agree that my/our signature(s) below release any and all claims against the Roman Catholic Diocese of Grand Rapids, or its associated entities related to or arising out of the Diocese’s use of the stated items as media relations/promotional material(s).