"I agree to support Countryside Baptist Church in their conduct regulations for my child while at the 2017 Countryside Youth Retreat. In case of a medical emergency, I understand every effort will be made to contact a parent or guardian of my child. In the event I cannot be reached, I hereby give permission to the physician selected by the Countryside leaders and/or onsite camp staff to hospitalize and secure proper treatment for and order injection and anesthesia or surgery for my child as named above. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I also affirm that the medical information on this form is complete and correct."