By submitting this form, you (being the parent of custody or legal guardian of the above named minor) do hereby appoint Temple Sinai Religious School, 509 Broadway, Saratoga Springs, New York 12866 to act on your behalf in authorizing unexpected medical, dental or surgical care, or hospitalization for the above named minor(s) in your absence.
This form is valid for a period of one year from the date signed.
Dated: 10/22/2017