PARENT/GUARDIAN PLEASE READ AND SIGN BELOW:
ALL prescription medications, over-the-counter medications, vitamins, and herbal products that are provided for staff to administer to your child MUST be in ORIGINAL containers with labels and dispensing instructions in English and COMPLETED medical form signed by doctor for all prescription medication.
PERMISSION TO ADMINISTER OVER THE COUNTER MEDICATIONS: In event of minor illness at camp, I give my informed consent to the First Aid personnel to provide basic First Aid and comfort measures which include the use of common over-the-counter remedies in appropriate age/weight dosages. I authorize the use of /but not limited to the following over-the-counter medications as directed by the labels provided by the manufacturer for my child: analgesics, decongestants, antihistamines, cough suppressant, throat lozenges or spray, anti-nausea/diarrhea, epi-pen, antacid, antibiotic ointment, hydrocortisone cream, burn cream, petroleum jelly, chapped skin/lip treatment, antiseptic skin/wound cleansers, ipecac, glucose, laxatives, electrolyte replacement fluids, analgesic balms/gels. I understand that these are stocked and dispensed by personnel free of charge as needed for the comfort of my child.
PERMISSION TO TREAT: I, the undersigned parent or legal guardian of the child named above, do hereby authorize and consent Youth Helpers, Inc., to provide to the above name child routine health care and to administer medications as detailed above. It is understood that in the case of an emergency every effort will be made to contact the undersigned prior to rendering treatment to the patient, but treatment will not be withheld if the undersigned cannot be reached. In case of emergency I authorize Youth Helpers, Inc. to order any x-ray examination, anesthetic, medical or surgical treatment rendered by medical or emergency professionals licensed under the provisions of the Medicine Practice Act, or dentist licensed under the provisions of the Dental Practice Act and on the staff of any general hospital in the state of CA, Department of Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care deemed advisable by aforementioned physician in the exercise of the doctor’s best judgement. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of CA. I authorize Youth Helpers to arrange for or provide any necessary related transportation to the nearest medical facility for urgent or emergency medical treatment if indicated, and I do assume all responsibility for payment for such treatment. This completed form may be photocopied for trips away from camp.
I acknowledge that I have read completely and fully understand all aspects of this form and I agree to the terms contained within them in their entirety.