YLC 2019 Medical Release & Consent Form

  • 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
  • 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.
  • 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 campers are required to have health insurance.
  • Name of the Insured * Required
  • Family Physician * Required
  • Address * Required
  • 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.