I give my consent and authority for the Rotary Youth Exchange Support System to take action to
help insure the safety, health, and welfare of my child. I also request and empower the Rotary Youth
Exchange Support System to authorize medical personnel and hospitals to provide appropriate medical care,
including but not limited to hospital tests, emergency surgical care, pathology, radiology and anesthesia, surgery
and prescriptive drugs for the health of my child. I further authorize these individuals to serve as my child’s
HIPAA Personal Representative for purpose of receiving medical information and communicating with medical
providers about my child’s medical condition