Authorization to Consent to Medical, Surgical, or Dental Examination or Treatment of a Minor and Authorization to Deal with Minors School

I, __________________________, being the mother of _________________________, a minor child, do hereby authorize __________________________________ of __________________, _______________, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor child under the general and/or special supervision and upon the advice of a physician and/or surgeon licensed to practice medicine in any state of the United States, or to consent to any X-ray, examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to said minor child by a dentist licensed to practice dentistry in any state of the United States. I direct any hospital, medical staff, or physician treating said minor child to give to _____________________ the same priority in visitations that would be extended to me as said minor child’s mother in the event that said minor child is a patient in any hospital or other health care facility. I authorize any school, day care, or similar institution providing services to me for my minor child, _______________, to release any and all records, information, or documentation relating to said minor child to _________________________. I further direct such school, day care, or institution to accept ________________’s signature or consent in lieu of mine with regard to parental authorization to enable said minor child to take part in outside or in-school activities or day care activities, to sign for report cards or similar notices, to provide notice of said minor child’s absence from school, and the like. I further authorize these acts as the sole physical and legal custodian of said minor child under the laws of the State of _________________________. In the event of emergency, I direct that the school, day care, or institution make a reasonable effort to contact _______________________________ and me immediately. I further direct that in a medical emergency the school, day care, or other institution has my permission to send said minor child immediately to a hospital with a trauma center that is reasonably close to the place where such medical emergency took place. I declare that any act lawfully done or authorized hereunder by _______________ shall be binding on myself, my heirs, legal and personal representatives, and assigns. I agree for myself, my heirs, and assigns to hold same harmless and indemnify all persons, hospitals, agencies, and/or institutions acting in reasonable reliance on the authority herein conferred. IN WITNESS WHEREOF, I have hereunto signed my name this ____ day of _________________, 20__ at ______________________, ______________. ________________________________ CLIENT’S NAME State of _______________ County of _____________ At ____________________________, __________________, on the ____ day of 20__, ___________________________ personally appeared before me. He/She acknowledged this instrument, by him/her sealed and subscribed, to be his/her free act and deed. ________________________________ Notary Public

Since 1985, KENNETH VERCAMMEN has worked as a personal injury attorney, working for injury victims and their families. By taking a hard-hitting, aggressive approach toward the insurance companies, KENNETH VERCAMMEN and our co-counsel have consistently obtained outstanding results for many injured clients over the years I am proud to have worked on cases in various capacities, small and large. While obviously prior results cannot guarantee the outcome of future cases, I can guarantee that you case will receive the same degree of dedication and hard work that went into each of these prior cases. In direct contrast to the hard-hitting approach we take toward the insurance companies is the soft approach we take toward our clients. I am proud of my compassionate staff as I am of the outstanding financial results they have achieved. For many years, I have watched them treat our clients with patience, dignity and respect. I would have it no other way. Many years ago, I attended a seminar sponsored by the American Bar Association on Law Practice Management. This was to help insure that each of our clients is always treated like a person -- not a file! We recognize that you are innocent victims and that you have placed your trust in us. Please understand that we understand what you are going through. Feel comforted that we are here to help you. If you retain KENNETH VERCAMMEN to represent you, we will give you the same advice we give each of our clients -- concentrate on your life, you family and your health. We will take care of everything else. Leave all of the work and worry about your legal rights to us. Trust us. Believe in us. Have faith in us as your attorneys. Understand that we will always to do what we believe is best for you and your case. Helping you is our job. In fact, it is our only job -- guiding injury victims like you through one of the most difficult times of your lives, with care and concern -- while fighting aggressively to the limits of the law to obtain compensation and justice for each of you! Print our Personal Injury Questionnaire on our Website, Fill it out and Fax back, so we can determine if we can help you obtain an injury settlement. We would welcome an opportunity to prove to you what we have proven to thousands of injured clients -- that you can feel comfortable and secure in the fact that KENNETH VERCAMMEN - Trial Attorney We Fight To Win. When you have been injured in an accident or collision, you are worried about who is going to pay your medical bills, lost wages, and other damages. The last thing you want is to be taken advantage of by an insurance company. If you dont protect your rights, you may not be able to make a claim. Insurance companies have attorneys and adjusters whose goal is to pay you as little as they can. You need a New Jersey personal injury lawyer to fight for you. I am dedicated to helping your recover as much money as possible under the law. You need an attorney who will work hard to protect your rights, maximize your insurance settlement and minimize the hassles of dealing with the insurance companies. You need an experienced and aggressive New Jersey trial lawyer with PROVEN RESULTS who will fight for you. Having an experienced personal injury lawyer can make the difference between getting what you deserve and getting nothing. Without the threat of a lawyer who is willing to go to trial and seek a big jury verdict, why would an insurance company pay you what your claim is really worth? Lawsuits can be expensive, and many people do not have the money to pursue their claim. In every case, I advance all costs associated with pursuing your case and I do not ask you for a penny until we recover from the other side. I am an experienced aggressive trial lawyer and a 3rd degree Black Belt. I am not afraid to take your case to trial if that is what it takes to maximize the amount of money your recover for your personal injury. I offer one-on-one service, and I will not hand your case off to an inexperienced lawyer or a paralegal. Reduce the stress of making a claim. Personal injury accidents can turn your life upside down. Making a personal injury claim can be difficult and time consuming. Once I take your case, you can stop worrying about dealing with the insurance companies and focus on recovering from your injuries. I take care of all of the paperwork, phone calls, and negotiations, so you can get on with your life. p.s. For those clients who are afraid or reluctant to go to Court, KENNETH VERCAMMEN also offers a special -- For Settlement Only -- program. This means that if we are unable to settle with the insurance company, we will not go any further -- unless you want us to. You have my personal assurance that there will be absolutely no pressure and no obligation. We handle personal injury cases on a contingency fee basis. This means: YOU DONT OWE ME A LEGAL FEE UNLESS I RECOVER MONEY FOR YOU. Call our office to schedule a "confidential" appointment 732-572-0500 Kenneth A. Vercammen is the Managing Attorney at Kenneth Vercammen & Associates in Edison, NJ. He is a New Jersey trial attorney has devoted a substantial portion of his professional time to the preparation and trial of litigated matters. He has appeared in Courts throughout New Jersey each week on personal injury matters, Criminal /Municipal Court trials, and contested Probate hearings. Mr. Vercammen has published over 125 legal articles in national and New Jersey publications on criminal, elder law, probate and litigation topics. He is a highly regarded lecturer on litigation issues for the American Bar Association, NJ ICLE, New Jersey State Bar Association and Middlesex County Bar Association. His articles have been published in noted publications included New Jersey Law Journal, ABA Law Practice Management Magazine, and New Jersey Lawyer. He is the Editor in Chief of the American Bar Association Tort and Insurance Committee Newsletter. Admitted In NJ, US Supreme Court and Federal District Court.