2017 Jr. NAD Medical Release and Consent Form

I understand that every effort will be made by the National Association of the Deaf to reach parents or guardians in case of emergency or when outside medical care is needed for my son or daughter during attendance at the 2017 Jr. NAD National Conference. In the event that I cannot be reached in an emergency, I hereby give permission to authorize National Association of the Deaf officials in attendance at the 2017 Jr. NAD Conference for medical attention as may be deemed necessary for my son or daughter named below.

I hereby give permission to National Association of the Deaf Conference officials to arrange EMT or ambulance transport for hospitalization or medical care for my child as named on the above line, should such become necessary. 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.

I understand that the National Association of the Deaf Conference officials will ensure that all student medications are sent with their school designated advisors. The National Association of the Deaf does not bear responsibility for student medications, and any over the counter medications procured during the conference are the responsibility of school-designated advisors.

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 costs 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 conference, for the purposes described herein. This authorization and consent shall be valid from November 7, 2017 through November 12, 2017.

I have read this consent form in its entirety and agree that the information I submitted is accurate and complete, that the completed form is not missing any substantial information that should be disclosed, and that typing my name at the end of this paragraph represents my electronic signature.

Parent/Guardian's eSignature*

Today's Date*

MonthDayYear

Information about Student Participant

Full Name*

First NameLast Name

Date of Birth*

MonthDayYear

Age*

Gender

Primary Emergency Notification

Full Name*

First NameLast Name

Relationship to Student Participant*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Daytime Phone Number*

Area CodePhone Number

Evening Phone Number

Area CodePhone Number

Text Number

Area CodePhone Number

E-mail*

Alternate Emergency Notification

Full Name*

First NameLast Name

Relationship to Student Participant*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Daytime Phone Number*

Area CodePhone Number

Evening Phone Number

Area CodePhone Number

Text Number

Area CodePhone Number

E-mail*

Student Participant's Health Insurance Information
*all participants are required to have health insurance

Insurance Company*

Name of Insured*

Student Participant’s Relationship to Insured*

Policy ID Number*

Group Name/Number

Family Physician's Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Emergency Phone Number*

Area CodePhone Number

Scan of Health Insurance (Front)*

Upload a File

Scan of Health Insurance (Back)*

Upload a File

if applicable, explain any specific requests or instructions regarding legal custody or foster care arrangements, i.e., visitation restrictions or authorization requirements.

Deadline: October 27, 2017