Emergency Medical Authorization

I,   First Name*   Last Name* parent/guardian of   First Name*   Last Name*   , date of birth being   Date*   , do hereby give permission to StarBright Applied Behavior Analyst PLLC, to secure and authorize such emergency medical care and/or treatment as above-named child might require while under the supervision of StarBright ABA. I further authorize StarBright ABA to administer emergency care/treatment as required, until medical assistance is available. I also agree to pay all costs and fees contingent on any emergency medical care and/or treatment for said child as secured or authorized under this consent.