(Pursuant to California Civil Code Sec. 25.8)
Name of Minor: _______________________________ Birth Date: _______________________
The undersigned does hereby authorize ________________________________ or such substitute as he may designate, as an agent for the undersigned to consent to an x-ray examination, anasthetic, medical, dental or surgical treatment, and hospital care for the above minor, which is deemed advisable by and to be rendered under the general or specific supervision of any physician and surgeon, licensed under the provision of Medical Practice Act, and/or Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital or elsewhere. This authorization will remain effective while the above minor is in route to and from, involved or participating in, the I Care Classic Bicycling Tour event, unless revoked in writing by the undersigned and delivered to the aforesaid agent.
Parent or Guardian signature: ______________________________ Date: ______________
Address: _____________________________________________ Phone #: _____________