Medical Treatment Authorization
This health history is correct and complete. The person described in this form has permission to engage in all camp activities except as noted within. I hereby give permission to Lunch, Learn and Play, at the Historic Salem Courthouse, to provide, seek, and consent to routine health care and emergency treatment for my child, as may be necessary, including, but not limited to x-rays, routine tests, and treatment, and/or hospitalization. I also permit the camp to arrange related transportation. I agree to release any records necessary for treatment, referral, billing, or insurance purposes.
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Lunch, Learn and Play to secure and administer treatment, including hospitalization, for the person named above.