I certify that my child is in good physical health and has my permission to participate in all the activities associated with Spring Arbor University clinics.

I authorize the directors of the clinic to act in their best judgment in any emergency requiring medical attention. I authorize all medical, surgical, diagnostic and hospital procedures as may be performed or prescribed by a treating physician for my child if I cannot be reached in an emergency.

I understand that either Spring Arbor University and the clinic directors, nor anyone else connected with eh clinic assumes any responsibility for accidents (medical or dental) or other injuries incurred as a result of attendance at this clinic.

I will furnish insurance for my child.