MEDICAL CONSENT

I hereby warrant that to the best of my knowledge, the child listed on this form is in good health, and I assume all responsibility for their health. FRATERNUS, INC. will take reasonable care to see that the information given remains confidential.

Medical Treatment: In the event it comes to the attention of the Ranch/Camp staff that the child listed on this form becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be contacted. In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event that I cannot be reached, I hereby give permission to the physician selected to hospital, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named herein.