MEDICAL EMERGENCY RELEASE FORM and PARENTAL AGREEMENT

                                                                                    Power of Attorney for Health Care

I, the undersigned and  custodial parent of _________________________________, hereby appoint the adult representative of Calumet Baptist Schools, Inc. as my attorney in fact for the purpose of providing health care and selecting any and all appropriate health care providers (as defined in I.C. 30-5-2-4,5) for the benefit of my child named above.  This power shall be valid from August 15, 2007  through August 14, 2008, and shall enable my attorney in fact named herein to provide medical care for my child in the event of injury, illness or other mishaps, and in my absence.

I also understand that my child (named above) will be engaging in physical activity during the program that may contain inherent risk of physical injury and agree that Calumet Baptist Schools, Inc. or the hosting location will not be held liable for personal injury occurring as a result of my child=s participation in the activities that comprise athletics at, on, or on behalf of Calumet Baptist Schools, Inc.   Neither the school, drivers, staff, or council will be liable to any suit whatsoever resulting from any injury occurring in practices, games or travel.

Signature of Parent/Guardian:___________________________________________Date__________

Personal Physician     ________________________________________________

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