MEDICAL TREATMENT AUTHORIZATION FOR A MINOR

We, the undersigned parents, hereby grant Maria Rose and Maria Rose, of 89 Palm Dr., Corte Madera, California 94920, the authority to obtain medical treatment for the following child(ren): Name of child: Birthdate: Adam Rothschild December 05, 2001

The above care provider(s) shall have the authorization to:
- obtain medical treatment and procedures for the child(ren) as may be appropriate in emergency circumstances, including treatment by physicians, hospital and clinic personnel, and other appropriate health care providers. - obtain routine medical treatment from appropriate health care providers if symptoms of illness occur (e.g., fever, coughing, irregular breathing, unusual rashes, swallowing problems, etc.).

This grant of temporary authority shall begin on April 17, 2012, and shall remain effective until terminated by the undersigned. In case of an emergency, the care provider(s) should first try to contact the parent(s). If the parent (s) cannot be reached, the care provider should then contact the following person(s) in the order listed below: Name: Relationship: Address: Ryan Jagger Uncle 35 Karr Ct. San Rafael, CA 94901 Initech (415) 847-3546 (415) 454-4441

Place of employment: Preferred phone number: Other phone number:

If the child(ren) need hospitalization, the preferred choice is: Hospital preference: Address: Dated: April 17, 2012 Kaiser Permanente 63 Santa Mira Way, San Rafael, CA, 94901

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____________________________________________ Dorian Rothschild

____________________________________________ Mary Rothschild Address: Preferred Phone: Alternate Phone: 60 Arthur St. San Rafael, CA 94901 (415) 454-1234 (415) 454-5555

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