I hereby give permission to the medical personnel to provide routine health care; to administer prescribed medications, and to administer emergency treatment for me, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation for me. I also agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. If the person named herein is a minor, it is my intention that representatives of the camp be considered 'personal representatives' for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to camp representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in camp activities; and if the person named herein is a minor, to provide information to the camp representatives to keep me informed of my child's health situation. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the named person. This completed form may be photocopied for trips out of camp.

I hereby give consent to Camp Cole to take and use images (photographs or videotape) or sounds recordings of me and/or the minor person named below for whom I am giving consent, and disclose confidential patient information about me and/or the minor patient or person, to or in any public media, including radio, television, internet or print, or in a Camp Cole publication. I understand that the intended use of such images and confidential information is for advertising, marketing, fundraising, or promotional purposes of Camp Cole. I acknowledge that this consent and authorization for the release of confidential information is being made solely for the benefit of Camp Cole and without any expectation of compensation or other benefits to the minor patient or person or the family thereof. To the extent that any benefit accrues or might accrue to Camp Cole from the use of images or disclosure of information, I hereby and forever waive any interest in or claim to such benefits. I hereby release and forever discharge Camp Cole (including without limitation all corporate affiliates and officers, directors, trustees, employees, medical staff members, and agents) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of images or disclosure of the information and materials described herein, and I hereby waive all rights and interest in and to such information and materials .I have been informed that once this information is disclosed it may no longer be protected by federal privacy regulations. I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying Camp Cole in writing at: PO Box 6377, Columbia, SC 29260.

Indecent assault and battery on a child under fourteen; Indecent assault and battery on a person with a disability; Indecent assault on a person who has obtained the age of fourteen; Rape; Assault with intent to commit rape; Kidnapping of a child under sixteen with intent to commit rape; Distribution and trafficking of narcotics or other controlled substances; Intent to commit any of the above crimes.

a) The camp may deny employment to any person who answers "yes" to any one of the above six questions. If hired and the employer later discovers circumstances that would indicate a "yes" to any of the previous six questions, employment may be terminated immediately. b) The information provided on this form is subject to verification, which may include a criminal history check and request from any Central Registry of child abusers. (A separate release form may be signed.) c) The camp may terminate employment or volunteer service of any person if that person is found, regardless of when discovered, to: 1) have a history of complaints of abuse of a minor2) have resigned, been terminated, or been asked to resign from a position whether paid or unpaid, due to complaint(s) of sexual abuse of a minor; and/or 3) have falsified or omitted information in this disclosure statement. d) This disclosure statement must be updated yearly and immediate notification provided to the camp if any information provided changes.

Please type your name in the box below to indicate you have answered these questions as accurately as possible.