Camper Medical Release and Consent

2025 YLC Camper Medical Release & Consent Form

"*" indicates required fields

Deadline: April 1, 2025

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 *

First Last

Parent/ Guardian Name *

First Last

Parent/ Guardian Email *

Camper’s Social Security Number *

Camper's BirthDate *

Camper's Age *

Camper's Gender *

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 July 2 – July 26, 2025

Signature

Primary Emergency Notification

Name *

First Last

Relationship to Camper *

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day-time phone *

Phone Type *

Evening phone *

Phone Type *

Email *

Alternate Emergency Notification

Name *

First Last

Relationship to Camper *

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day-time phone *

Phone Type *

Evening phone *

Which method? *

Email *

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 *

Name of the Insured *

First Last

Camper’s Relationship to the Insured *

Policy ID Number *

Group Name/ Number *

Family Physician *

First Last

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone *

Emergency Phone *

Upload Side #1 of your Health Insurance Card *

Max. file size: 300 MB.

Upload Side #2 of your Health Insurance Card *

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 23, 2024 and June 25, 2025. Exams done before July 23, 2024 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.