2019 Jr. NAD Medical Release and Consent Form

Deadline: October 27, 2019

I understand that every effort will be made by the National Association of the Deaf to reach parents or guardians in case of emergency or when outside medical care is needed for child during attendance at the 2019 Jr. NAD National Conference. In the event that I cannot be reached in an emergency, I hereby give permission to authorize the National Association of the Deaf officials in attendance at the 2019 Jr. NAD Conference for medical attention as may be deemed necessary for my child named below.

I hereby give permission to the National Association of the Deaf Conference officials to arrange EMT or ambulance transport for hospitalization or medical care for my child as named on the above line, should such become necessary. 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.

I understand that the National Association of the Deaf Conference officials will ensure that all student medications are sent with their school designated advisors. The National Association of the Deaf does not bear responsibility for student medications, and any over the counter medications procured during the conference are the responsibility of school-designated advisors.

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 conference, for the purposes described herein. This authorization and consent shall be valid from November 6, 2019 through November 10, 2019.

I have read this consent form in its entirety and agree that the information I submitted is accurate and complete, that the completed form is not missing any substantial information that should be disclosed, and that typing my name at the end of this paragraph represents my electronic signature.

  • Date Format: MM slash DD slash YYYY
  • Child Name * Required
  • Date Format: MM slash DD slash YYYY
  • -- Primary Emergency Notification --
  • Name * Required
  • Address * Required
  • -- Alternate Emergency Notification --
  • Name * Required
  • Address * Required
  • -- Insurance Company --
  • Name of Insured * Required
  • Family Physician's Name * Required
  • Family Physician's Address * Required