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SIZE NOT GUARANTEED IF REGISTRATION RECEIVED AFTER DUE DATE.
Please read each of the following paragraphs, requesting you select the box next to "I DO", carefully. Indicate your understanding of, and consent to, the contents and conditions for each paragraph by selecting the check box next to "I DO" at the end of each paragraph. Selecting "I DO" will stand place for Initialing on this form. If you have any questions regarding each paragraph, contact the Miami County Sheriff’s Office before "initialing" the paragraph.
(1) The administration of any treatment deemed necessary by the physician or dentist specified below (if any), or in the event the specified practitioner is not available or no practitioner has been specified, then by another licensed physician or dentist; and
(2) The transfer of the child to any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity for surgery are obtained in writing prior to the surgery.
YOUR ELECTRONIC SIGNATURE BELOW INDICATES YOUR AGREEMENT WITH THE FOLLOWING STATEMENTS: BY TYPING MY NAME IN THE FOLLOWING BOX AND CLICKING THE SUBMIT BUTTON I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
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