Releases and Authorizations: please sign and initial as directed
This Registration & Health History is correct and complete as far as I know. The person herein named as "camper" has permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide, seek, and consent to routine health or dental care, administration of prescribed medication, and emergency treatment for me/my child, as may be deemed necessary, including but not limited to x-rays, routine tests, and treatment, and/or hospitalization.I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that the camp be treated as acting in loco parentis if the person herein named is a minor. Further it is my intention that the appropriate representatives of the camp be treated as "personal representatives" for the purposes of disclosing protected health information pursuant to the Health Insurance Portability and Accountability act of 1996. I hereby agree (pursuant to 45CFR$164.510(b to the disclosure to camp representatives of the protected health information of the person herein described, as necessary; (1) to provide relevant information to the camp representatives related to the person's ability to participate in camp activities; and (2) in the case of minors, relevant information to the camp representatives to keep me informed of my child's health status. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. Please initial Transportation, Photography, and Medication Releases: