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2021 YLC Camper Medical Release and Consent Form

  • Deadline: March 1, 2021 for Session 1 and May 1, 2021 for Session 2

    I understand that every effort will be made by NAD Youth Leadership Camp officials to reach my parents or guardians in case of emergency or when outside medical care is needed. In the event that my parents or guardians cannot be reached in an emergency, I hereby give permission to authorize NAD Youth Leadership Camp officials to order X-rays, routine tests, and any other treatment as may be deemed necessary for me named below.

  • Camper's Name * Required
  • And I hereby give permission to the physician selected by the camp officials to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for me as named on the above line.

    I hereby give permission for camp officials to administer medications as deemed necessary to me. This includes medications sent with me, or non-prescription medications available at the camp or prescriptions ordered by a physician during the camp session. I understand that any medical expenses will be billed directly to my insurance carrier. The hospital and/or medical facility will be instructed to forward the bill to me if my insurance carrier does not follow through with the payment after a period of time.

    Further, I hereby release the National Association of the Deaf and its officers, directors, employees, agents, and subcontractors, from any and all liability for bodily injury, or costs of medical treatment thereof, or injury incurred as a result of the administration of emergency treatment. This form may be photocopied for use outside of the camp, for the purposes described herein. The camp will charge me for any prescriptions and/or medications ordered by the physician that we do not stock. This includes dental-related concerns.

    The authorization and consent shall be valid from June 22 – July 12, 2021 for Session 1 and July 15 – August 4, 2021 for Session 2.

  • Date Format: MM slash DD slash YYYY
  • This information will only be shared with the Director of Youth Programs and the Camp Nurse.

  • Primary Emergency Notification

  • Name * Required
  • Address * Required

  • Alternate Emergency Notification

  • Name * Required
  • Address * Required

  • Health Insurance Information

  • Note: all campers are required to have health insurance. If you do not have health insurance, please contact Chanel Bonheyo

  • Name of the Insured * Required
  • Family Physician * Required
  • Address * Required
  • Drop files here or
    Accepted file types: pdf, doc, docx, jpg, gif, png, jpeg.
  • Accepted file types: pdf, doc, docx, jpg, jpeg, jiff, png, gif, rtf.
    Attach, if applicable, written explanation for any specific request or instructions regarding legal custody or foster care arrangements, i.e. visitation restrictions or authorization requirements.
  • Important Note:

    The camper's doctor must complete the separate Health Form. Be sure that the exam is done between August 5, 2020 and June 1, 2021 (for Session 1) and July 1, 2021 (for Session2). Exams done before August 5, 2020 will not be accepted.

    All medications brought to camp by camper must be in containers that are clearly labeled with the name of camper, the name of the medication, the dosage, the frequency of administration and the route of administration. All medication prescribed by a physician must, in addition, be labeled with the name of the prescribing physician, the prescription number, date prescribed, possible adverse reactions, the specific conditions when contact should be made with the physician and other special instructions as needed.