I allow the minor listed above to participate in the event on the dates and at the location listed above. If I am unable to be reached, I give FCC New Salem, by its representative, to hospitalize, secure treatment for, and to order anesthesia or surgery for my child named above. I further agree to be responsible for any and all bills incurred for such treatment. I, hereby, give full authority to the representative of FCC New Salem to use his/her discretion in determining if such medical treatment is necessary, and I release FCC New Salem (i.e. representative, chaperone) from any and all responsibility for the results of that determination. I further release FCC New Salem (i.e. representative, chaperone) from any responsibility other than normal supervision and care of my child. By signing, I have accurately completed this form and reviewed the agreement statement.