I, the undersigned, am the parent or legal guardian of this minor and have given my consent for him/her to participate in activities hosted by Coda Mountain Academy. In the event of injury, accident, illness or other emergency while participating in the camp, I consent to any reasonable medical treatment as deemed necessary by a licensed physician, emergency medical technicians, nurses, and laboratory technicians. In the event any treatment is required, which a physician and/or hospital personnel refuses to administer without my consent, I hereby authorize Esther Morey, Lauren Floyd, Kathy Claywell, Crystal Bennett, or an associated adult supervisor to give such consent for me, if I cannot be reached by telephone at one of the numbers listed above, or because of an emergency in which there is no time or opportunity to make a telephone call. In the event it becomes necessary for that person to give consent for me, I agree to hold such person, other associated adults and Coda Mountain Academy free and harmless of claims, demands, or suits for damages which may arise from the giving of such consent. I also acknowledge that I accept to be ultimately responsible for the cost of any medical care whether or not the cost of that medical care will be reimbursed by my health insurance provider. Further, I affirm that the health insurance information provided in the medical release form is accurate as of this date. I further authorize disclosure of medical information by a treating physician to Esther Morey, Lauren Floyd, Kathy Claywell, Crystal Bennett or associated adult supervisor as permitted by The Health Insurance Portability and Accountability Act of 1996 (HIPAA).