Lebanon Valley College Summer Camp Health Information and Consent for Treatment

Student Information

This form must be completed and returned before the start of the Summer Camp.

No exceptions are permitted.

contactid

Summer Camp

First Name

Last Name

Email

Birthdate

Gender

Mobile Phone

Can we contact you by text message? (Mobile phone number required. Standard messaging rates may apply)

Year of Graduation

Mailing Street

Mailing State

Mailing City

Mailing Zip

Parent/Guardian Information

Parent/Guardian 1

Relationship

First Name

Last Name

Email

Mobile Phone

Can we contact you by text message? (Mobile phone number required. Standard messaging rates may apply)

Alternate Phone Number

Parent Guardian 2

Relationship

First Name

Last Name

Email

Mobile Phone

Can we contact you by text message? (Mobile phone number required. Standard messaging rates may apply)

Alternate Phone Number

Health Insurance Information

Health Insurance Carrier

Policy Number

Group/Plan Number

Family Physician Name

Family Physician Phone Number

Emergency Contacts

If parent(s) are unavailable

Emergency Contact 1

Relationship

First Name

Last Name

Email

Phone Number

Can we contact you by text message? (Mobile phone number required. Standard messaging rates may apply)

Emergency Contact 2

Relationship

First Name

Last Name

Email

Phone Number

Can we contact you by text message? (Mobile phone number required. Standard messaging rates may apply)

Health Information

Allergies

Shift + Click to select additional options

Allergies - Other

Medical Conditions

Shift + Click to select additional options

Medical Conditions - Other

Date of most recent tetanus immunization

List any Chronic Illnesses/Conditions, Serious Injuries, or Hospitalizations

Please indicate any dietary needs or restrictions

Dietary Restrictions - Other

Is there anything else we should know about Participant’s health? If yes, explain

Will the Participant need to take any medications during the Program?

YesNo

Medication

List the specific prescription or over-the-counter medications below and the reason for the medication. Participants are required to self-administer all medications required during the Camp because there are no medical staff on site.

Medication, Reason for medication, and Time(s) Taken

Medication

Reasons

Time(s) Taken

All medications must be stored in the original product packaging and clearly labeled with the Participant’s name. The label on prescription medications must also include the medication name, dosage instructions, and the prescribing physician’s name and phone number. All non-emergency medications will be kept in a locked cabinet or refrigerator (where refrigeration is required). Approved personnel will provide access, when requested, for Participants to self-administer medications in accordance with dosage instructions. Any emergency medications required (epi-pens, inhalers, etc.) must be disclosed above, but will caried by the Participant rather than stored. Medications not retrieved by the end of the Camp will be discarded.

I certify that the Health Information provided above is accurate and complete.

I understand and agree to the provisions above relating to the management and self-administration of medications. I understand that medications provided for a Participant may not be shared with any other Participant.

I affirm that Participant is physically and mentally fit to participate in the Program and that I am solely responsible for consulting with health care providers regarding the advisability of Participant’s participation in the Program.

I understand that Participants are recommended to have a meningococcal vaccine prior to attend the Camp.

I understand that in the event the Participant becomes ill or contracts any potentially infectious disease during the Camp, the Participant will be excluded from activities, and I will be required to transport the student home.

CONSENT TO MEDICAL TREATMENT: I understand that Lebanon Valley College will not have medical personnel available. In the event that medical treatment of the Participant is required at any time during the Camp, I understand that reasonable efforts will be made to contact me. In the event of an emergency, or if I (or another Parent/Guardian cannot be reached), I authorize Lebanon Valley College to arrange for Participant to be transported to a medical facility and I authorize Lebanon Valley College to consent to Participant receiving any emergency medical care recommended by medical practitioners.

I understand that Lebanon Valley College does not provide health insurance to cover any costs of medical care or treatment of Participant. I understand that I, or health insurance that I provide will be solely responsible for the costs of any medical care or treatment provided to Participant during the Camp.

CONFIENTIALITY STATEMENT: Lebanon Valley College is committed to protecting the privacy of health information provided. Information provided will be maintained and used only as necessary to provide services to the Participant during the Camp.

By my signature below, I confirm my understanding and agreement to the Health Information and Consent For Treatment.

Date

Printed Name of Parent or Guardian