Authorization *
This health history is correct and complete to the best of my knowledge. The Participant has permission to engage in all camp activities except as noted in this form. In case of emergency, camp directors may make necessary referrals to hospitals including but not limited to Mountainside Hospital, Montclair, NJ. I grant permission for transportation to and treatment at such local hospital or healthcare facility. I understand that any diagnosis, treatment, and/or transportation will be my sole financial responsibility. I agree to the disclosure to camp staff of the protected health information of the Participant. I grant permission for the release of such health information to non-camp healthcare providers who may need to administer treatment to Participant and permit the photocopy of this form for use in those situations. I also agree to the release of any records necessary for insurance or billing purposes. I give permission for a photocopy of this form to be used for the release of records.