Student

The health history reported in this application is correct so far as I know and the above named minor has permission to engage in all prescribed program activities except as noted. The undersigned do hereby authorize the directors of Bethlehem Family Camp or such substitute as they may designate as agent for the undersigned to consent lo an X-Ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the provision of the Medicine Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp or elsewhere. This authorization will remain effective while the above minor is en route lo and from or involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Director of Bethlehem Family Camp as legal guardian/social worker/other.