This health history is correct and accurately reflects the health status of the minor to whom it pertains. The person described has permission to participate in all activities except as noted by me and/or an examining physician. I give permission, in case we cannot be reached, to the physician selected by the church to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with church staff. I give permission to photocopy this form. In addition, the church has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.