This health history is correct to the best of my knowledge, and the person

herein as described has permission to participate in all camp activities except

as listed above. In the event that I can not be reached in an emergency,

I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for and order injection, anesthesia,

or surgery for my child as named above.

My son/daughter has had a physical recently and may participate in all

activities at the UB Camp. I give permission for my son/daughter to be

treated by a certified athletic trainer or licensed physician. I further agree

that the UB Camp staff should be held harmless from and indemnified

against any and all liability, cost claims, loss or damage which it or they

may incur as a result of an accident or injury to my child.