I,_____________________________ (Parent/Guardian's Name) hereby give permission for

any and all medical attention to be administered to my child _________________________

(Child's Name) In the event of accident, injury, sickness, etc., under the direction of

the person(s) listed below, until such time as I may be contacted. I also assume the

responsibility for the payment of any such treatment. This release is effective for

the period of one year from the date given below.

ADDRESS: _____________________________________________________________________

 _____________________________________________________________________

HOME PHONE:________________________________________________________

INSURANCE CO.:______________________________________________________

POLICY NUMBER:_____________________________________________________

In case I cannot be reached, any of the following persons is designated to act on my behalf.

 A JGMXT representative where my child is training.

PHYSICIAN: ____________________________________________________________

ADDRESS: _____________________________________________________________

PHONE: _______________________________________________________________

KNOWN ALLERGIES:____________________________________________________

SIGNATURE (PARENT/GUARDIAN) ________________________DATE___________

Subscribed and sworn before me,

this ______ day of __________________ , 200__________

________________________________________________
Notary Public