Staff Medical Release and Consent

2024 YLC Staff Medical Release and Consent Form

Deadline: June 1, 2024
Name * Required
First Middle Last
Email * Required
I 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 me.

I give permission for camp officials to administer medications as deemed necessary. This includes medications brought with me, or non-prescription medications available at the camp or prescriptions ordered by a physician during camp session.

Below is a list of common OTC medications and the reason medication would be used. Please put a check beside each medication that you can take. Dosage will be according to label guidelines by the age and/ or weight.
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)
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.
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 18 – July 23, 2023.
eSignature * Required
SSN * Required
Birthdate * Required
MM slash DD slash YYYY
Age * Required
Gender * Required
Primary Emergency Notification
Name * Required
First Last
Relationship to staff member * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime phone number * Required
Which method is the daytime number? * Required
Evening phone number * Required
Which method is the evening number? * Required
Email * Required
Alternate Emergency Notification
Name * Required
First Last
Relationship to staff member * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime phone number * Required
Which method is the daytime number? * Required
Evening phone number * Required
Which method is the evening number? * Required
Email * Required
Health Insurance Information
Note: all staff members are required to have health insurance. If you do not have health insurance, please contact [email protected].
Insurance Company: * Required
Name of the Insured * Required
First Last
Staff Member'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 number * Required
Health Insurance Card (upload front and back) * Required
Drop files here or

Accepted file types: pdf, doc, docx, jpg, gif, png, jpeg, Max. file size: 300 MB.
Important Note:
The staff’s doctor must complete the Health Form. Be sure that the exam is done between July 24, 2022 – June 17, 2023. Exams done before July 24, 2022 will not be accepted.

All medications brought to camp by staff must be in containers that are clearly labeled with the name of staff, 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. All medications must be kept in the Health Center when campers are on site.