2019 YLC Staff Medical Release & Consent Form

Deadline: June 16, 2019

  • 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.
  • 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 July 12 - August 19, 2018.
  • Date Format: MM slash DD slash YYYY
  • Primary Emergency Notification
  • Name * Required
  • Address * Required
  • Alternate Emergency Notification
  • Name * Required
  • Address * 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]
  • Name of the Insured * Required
  • Family Physician * Required
  • Address * Required
  • Drop files here or
    Accepted file types: pdf, doc, docx, jpg, gif, png, jpeg.
  • Important Note: The staff’s doctor must complete the Health Form. Be sure that the exam is done between August 14, 2018 and June 16, 2019. Exams done before August 14, 2018 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.