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.

Parent/Guardian Information

Parent/Guardian 1

Parent Guardian 2

Health Insurance Information

Emergency Contacts

If parent(s) are unavailable
Emergency Contact 1

Emergency Contact 2

Health Information

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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.

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.