National Association of the Deaf

Deadline: May 1, 2019
I understand that every effort will be made by the NAD Youth Leadership Camp officials to reach my parents and 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 official to order X-rays, routine tests, and any other treatment as may be deemed necessary for me named below.
Camper's Full Name * Required
First Middle Last
Your Email * Required
And I hereby give permission to the physician selected by 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 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 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 17 - August 12, 2019.
eSignature of Parent/Guardian * Required
Camper’s Social Security Number * Required
Camper's BirthDate - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Camper's Age * Required
Camper's Gender * Required
Camper's Religion * Required
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
Which method? * Required
Evening phone * Required
Which method? * 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
Which method? * Required
Evening phone * Required
Which method? * Required
Email * Required
Health Insurance Information Note: all campers are required to have health insurance.
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
Upload Side #2 of your Health Insurance Card * Required
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.
Important: The camper’s doctor must complete the Health Form. Be sure that the exam is done between August 11, 2018 and June 16, 2019. Exams done before August 11, 2018 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.