Camper Medical Release and Consent

2023 YLC Camper Medical Release & Consent Form

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Deadline: April 1, 2023
We, as the parents/guardians and camper, understand that every effort will be made by the NAD Youth Leadership Camp officials to reach the authorized persons (e.g., parents or guardians) in case of emergency or when outside medical care is needed. In the event that these authorized persons (e.g., parents or guardians) cannot be reached in an emergency, we hereby give permission to authorize NAD Youth Leadership Camp officials to consent to any medical procedure including but not limited to: X-rays, routine tests, and any other treatment as may be deemed necessary for me named below.
Camper's Full Name * Required
First Last
Parent/ Guardian Name * Required
First Last
Parent/ Guardian Email * Required
Camper’s Social Security Number * Required
Camper's BirthDate * Required
MM slash DD slash YYYY
Camper's Age * Required
Camper's Gender * Required
Camper's Religion
We give permission to the physician selected by camp officials to hospitalize, secure proper treatment for, order injections and/or anesthesia, and/or arrange for surgery for the camper as named on the above line.

We give permission for camp officials to administer medications as deemed necessary to the above named camper. This includes medications sent with the camper, or non-prescription medications available at the camp or prescriptions ordered by a physician during camp session. We understand that any medical expenses will be billed directly to our insurance carrier. The hospital and/or medical facility will be instructed to forward the bill to us if our insurance carrier does not follow through with the payment after a period of time.
Below is a list of common OTC medications and the reason medication would be used. Please put a check beside each medication you give permission for your child to take. Dosage will be according to label guidelines by the age and/ or weight of your child.
Analgesic/Pain Reliever/ Fever Reducer
- Acetaminophen(Tylenol)
- Ibuprofen (Advil, Motrin)
Antihistamine/seasonal allergy/Runny Nose
- Diphenhydranine (Benadryl)
- Loratadine (Claritin)
- Chlorpheniramine (Chlor-Trimeton)
Ointment for itchy, irritated skin
- Calamine lotion or Calegel
- Aloe or burn gel
- Sun screen(SPF15 or above)
- None scented lotion
- Hydrocortisone cream
Cold and cough
- Guaifenesin (Robitussin)
- Mentholatum(Vicks Rub)
- Cough drops or throat lozenges
- Chloraseptic spray
Antibiotic ointment/cuts or scrapes, Eye Irrigation
- Visine AC
- Eye Wash/ Drops
Other
- Antacid (Tums)
- Lip balm or petroleum jelly (Vaseline)
Further, we release the National Association of the Deaf and its officers, directors, employees, agents, and subcontractors, from any and all liability for bodily injury, or cost 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 26 - July 21, 2023.
Signature
Primary Emergency Notification
Name * Required
First Last
Relationship to Camper * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day-time phone * Required
Phone Type * Required
Evening phone * Required
Phone Type * Required
Email * Required
Alternate Emergency Notification
Name * Required
First Last
Relationship to Camper * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day-time phone * Required
Phone Type * Required
Evening phone * Required
Which method? * Required
Email * Required
Health Insurance Information Note: all campers are required to have health insurance. If a camper does not have health insurance, please contact us at [email protected]
Insurance Company * Required
Name of the Insured * Required
First Last
Camper’s Relationship to the Insured * Required
Policy ID Number * Required
Group Name/ Number * Required
Family Physician * Required
First Last
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone * Required
Emergency Phone * Required
Upload Side #1 of your Health Insurance Card * Required
Max. file size: 300 MB.
Upload Side #2 of your Health Insurance Card * Required
Max. file size: 300 MB.
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.
Max. file size: 300 MB.
Important: The camper’s doctor must complete the Health Form. Be sure that the exam is done between July 22, 2022 and June 25, 2023. Exams done before July 22, 2022 will not be accepted. All medications brought to camp by a camper must be in containers that are clearly labeled with the name of camper, the name of 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 prescribing physician, the prescription number, date prescribed, possible adverse reactions, the specific condition when contact should be made with the physician and other special instructions as needed.