This health history is correct and accurately reflects the health status of the person to whom it pertains. The person described has permission to participate in all camp activities except as noted by an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to my health for both routine health care and in emergency situations. In an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or suergery while my emergency contact person is being contacted. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my health record from providers these providers may talk with the program's staff about my health status.