DESIGNATION OF MINOR CHILD’S HEATH CARE SURROGATE BY THIS DESIGNATION OF MINOR CHILD’S HEALTH CARE SURROGATE (the “Designation”) I, ________________________of ________________________________County, _______________ (State), hereby acknowledge and affirm that I am the natural parent_____, custodial parent___________ or the legal guardian _______ (check one) of ________________________, (the “Minor Child”) and I designate as the surrogate for the health care decisions of the Minor Child (the “Minor Child’s Health Care Surrogate”),shall be representatives of MTF, which is a camp and program in which the Minor Child participates. Each of the following representatives of MTF has my consent and are authorized to act on behalf of Minor Child as the Minor Child’s Health Care Surrogate as permitted in this Designation: Name: Position/Office: 1. Colleen Millsaps, Owner 867 Bold Springs Road, Cairo, Georgia, 39828. 2. Bryan Johnson, Sr. General Manager 867 Bold Springs Road, Cairo, Georgia, 39828. 3. Bryan Johnson, Jr. Head Trainer 867 Bold Springs Road, Cairo, Georgia, 39828. Minor Child’s Heath Care Surrogate shall serve subject to the following: 1. Powers: Minor Child’s Health Care Surrogate shall have full authority to make decisions for Minor Child regarding Minor Child’s heath care, during the period in which the Minor Child is registered and participates in the camp, program and activities of MTF, and immediately subsequent during any period of treatment, recovery and/or convalescence as the result of an illness or injury which occurred during the Minor Child’s participation in the camp, program and activities of MTF. In the exercise of such authority, Minor Child’s Heath Care Surrogate shall follow my desires as the Minor Child’s legal guardian and as stated in this document or otherwise known to Minor Child’s Heath Care Surrogate, and if such surrogate is unable to determine the choice I would want to be made, shall make a choice for Minor Child, on my behalf based upon what such surrogate believes to be in the best interests choice of the Minor Child. Minor Child’s Health Care Surrogate’s powers shall include but shall not be limited to the following: (a) To consult with Minor Child’s health care providers regarding Minor Child’s health care and treatment. (b) To provide consent in writing with respect to any and all types of health and medical care, treatment, procedures and medication, or to withhold consent or withdraw consent to any of the foregoing, with the exception that the Minor Child’s Health Care Surrogate shall not have the authority to withhold or withdraw any life support health care, treatment, procedures, or equipment. (c) To have access to any and all of Minor Child’s medical records and information limited to that protected health information and medical records related to any and all illness or injury which occurred during the Minor Child’s participation in the camp, program and activities of MTF and to authorize release of such information to appropriate persons. (d) To authorize Minor Child’s admission or transfer to or discharge from any health care facility, rehabilitation or assisted living facility or nursing home. (e) To contract on Minor Child’s behalf for any health care services without incurring personal financial liability for said services, including the power to hire and fire any medical or other persons responsible for Minor Child’s health care. (f) To do and perform every other act whatsoever relating to Minor Child’s health care as fully and with the same validity and legal effect as if such act had been specifically listed herein. 2. When Effective. Minor Child’s Health Care Surrogate named herein shall have the authority and power to act on Minor Child’s behalf during such time as I am and all other legal guardians have been determined to be unavailable or incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures. 3. Revocation. This Designation of Minor Child’s Health Care Surrogate shall terminate upon the first to occur of the following: (a) The execution by me, on behalf of Minor Child, of a signed, dated written revocation of this Designation of Minor Child’s Health Care Surrogate; (b) The execution by me of another Designation of Minor Child’s Health Care Surrogate after the date I execute this Designation of Minor Child’s Health Care Surrogate; (c) Physical cancellation or destruction of this Designation of Minor Child’s Health Care Surrogate by me or by another person in my presence and at my direction; or (d) One (1) year after the effective date of this Designation of Minor Child’s Health Care Surrogate which is the date this Designation of Minor Child’s Health Care Surrogate was signed.

4. Reliance. Minor Child’s Health Care Surrogate and all health care facilities and health care providers shall be entitled to rely upon this Designation of Minor Child’s Health Care Surrogate unless or until such person or facility receives actual notice of the revocation of this Designation of Minor Child’s Health Care Surrogate by a subsequent writing. No person who relies in good faith on a health care decision or direction made pursuant to this Designation shall be liable therefore to me, my estate, my heirs or assigns and/or my interest in Minor Child’s estate. 5. Indemnity. My estate and my interest in Minor Child’s estate shall hold harmless and indemnify Minor Child’s Health Care Surrogate from all liability for acts done in good faith on Minor Child’s behalf pursuant to this Designation of Minor Child’s Health Care Surrogate. 6. Miscellaneous Provisions. (a) I hereby revoke any designation of the Minor Child’s Health Care Surrogate made prior to the date hereof. (b) This Designation and all powers and authority set forth herein shall not be affected by any subsequent incapacity that I may suffer except as provided by applicable law. (c) This Designation is intended to be valid and legally binding in any jurisdiction in which it may be presented. (d) I hereby affirm that this Designation is not being made as a condition of treatment or admission to a health care facility. (e) Any person may rely upon a fully executed photocopy of this Designation to the same effect as if it were the original hereof. (f) Minor Child’s Health Care Surrogate shall be considered the Minor Child’s personal representative for health care disclosure limited to that protected health information and medical records related to any and all illnesses or injuries which occurred during the Minor Child’s participation in the camp, program and activities of ______________________, under applicable federal HIPPA rules and regulations including 45 C.F.R. § 164.502. (g) I fully understand the full import of this Designation, and I am emotionally and mentally competent to make this Designation. Dated this ___ day of ______________, 2015. WITNESSES: ON BEHALF OF MINOR CHILD 1.__________________________________________________________________________________ Natural Parent/Custodial Parent/ Legal Guardian ___________________________________________________________________________________ Print name Print name 2._______________________________________________ Print name STATE OF __________ COUNTY OF _________ Before my personally appeared ____________ to me well known to me to be the person described in and who executed the foregoing instrument, and acknowledged before me that she executed the same instrument for the purposes therein expressed. WITNESS my hand and official seal this ______day of ____________, 2015 ___________________________________ NOTARY PUBLIC, STATE OF ___________________________________ Print, Type or Stamp name of Notary Personally known_____or Type of Identification Produced __________________