Youth Programs Consent for Treatment
2025-2026 TERM
This form must be completed once to participate in the 2025-2026 school term and summer programs
Personal Information
Youth's Name
*
First Name
Last Name
*
M
F
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Format: (000) 000-0000.
E-mail Address
*
example@example.com
Parent/Guardian #1
*
Daytime Phone
*
Format: (000) 000-0000.
Place of employment
*
Parent/Guardian #2
*
Daytime Phone
*
Format: (000) 000-0000.
Place of employment
*
Name of Physician
*
Physician's Phone Number
*
Format: (000) 000-0000.
In case of emergency, please notify
Name of Emergency Contact #1
*
Phone Number for Emergency Contact #1
*
Format: (000) 000-0000.
Name of Emergency Contact #2
*
Phone Number for Emergency Contact #2
*
Format: (000) 000-0000.
Health History [Please check and provide approximate dates that youth suffered from allergies and other conditions listed below]
Allergies
Hay Fever
Bee/Wasp Stings
Insect Stings
Penicillin
Peanut
Other
Other
Asthma
Diabetes
Convulsions
Concussion
Behavioral/Emotional
Other
Date of most recent tetanus immunization:
*
Please list any major past illnesses (contagious and non-contagious):
Please list any major operations or serious injuries (include dates):
Has the youth ever been hospitalized?
*
NO
Yes
If YES, explain:
Does the youth have any chronic or recurring illness?
*
NO
Yes
If YES, explain:
Is there anything else in youth's health history that the program staff should know?
Are there any activities from which the youth should be restricted?
*
NO
Yes
If YES, explain:
Are there any specific activities that should be encouraged?
*
NO
Yes
If YES, explain:
Does the youth have any special dietary restrictions?
*
NO
Yes
If YES, explain:
Does the youth wear any medical appliances (glasses, contact lenses, orthodonture, etc.)?
*
NO
Yes
If YES, explain:
Will the youth need to take any medication during the program?
*
NO
Yes
If YES, please list the specific prescription or over-the-counter medications below, reasons for medication, and daily dosage. If any medications change prior to arriving at the program, please provide an updated list upon arrival.
Rows
Reason(s) for Medication
Daily Dosage/Time(s) Taken
1.
2.
3.
If at all possible, medication should be administered at home. Medications will be allowed at the Youth Program only when failure to take such medicine would jeopardize the health of a child and he/she would not be able to attend the Youth Program if the medicine were not made available.
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The Community Education Center Youth Program Consent for Treatment - Page 2
The parent(s)/legal guardian(s) of Youth Program participants are required to disclose their intention to bring medications to the Program, especially to treat potentially life-threatening conditions (i.e. inhalers, EPI-pens, insulin injections). Upon arrival to the Program, parent(s)/legal guardian(s) should plan to meet with a member of the Youth Program staff to review medication issues for a Youth Program participant
All medications (prescription and over-the-counter) must be stored in the original product packaging and clearly labeled with the participant's name. Prescription medication(s) must also include a label with the medication's name and dosage instructions, as well as the prescribing physician's name and telephone number.
The need for emergency medication may require that a Youth Program participant carry the medication on his/her person or that it be easily accessed (i.e. inhalers, EPI-pens, insulin injections). Program staff will NOT purchase medications of any type (prescription or over-the-counter) for Youth Program participants of any age.
Program staff will not dispense medications, but may monitor the self-administration of certain medications if necessary, ONLY upon written consent of the parent(s)/legal guardian(s) and /or physician's orders.
It is NOT permissible for a participant to share any medications with any other participants.
It is the responsibility of the parent(s)/legal guardian(s) to be sure that the participant's medications brought to the Youth Program are not left behind at the end of the Program. Failure to do so will result in the medications being destroyed within three working days after the last day of the Program. Absolutely no medications will be returned via mail regardless of circumstance.
I hereby authorize licensed health care practitioners, acting within the scope of his or her practice under State law, to provide medical care that includes routine diagnostic procedures (e.g., x-rays, blood and urine tests) and medical treatment as necessary to my minor daughter/son/dependent. I understand that the consent and authorization herein granted does not include major surgical procedures and is valid only during the Youth Program/event.
In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency and if I cannot be reached, I give my consent for licensed health care practitioners to perform any necessary emergency treatment.
I agree to the release of records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care provider. I may be responsible to submit any claims to my health insurance carrier for reimbursement.
I understand that, unless specifically stated otherwise the Community Education Center does not provide medical insurance to cover emergency care or medical treatment of my child.
I understand that, in accordance with Youth Program policy, any medication(s) should be given at home before and/or after the Youth Program. However, when this is not possible, and medications will be brought to Youth Program camp, I agree to the provisions outlined above relating to the management of medications.
Medical and Related Health Information the Community Education Center is committed to protecting the medical and related health information about your child. Medical and related health Information provided on this form will only be used as the Community Education Center deems necessary to provide services for your child while participating in the Youth Program. Information will be stored, archived, and disposed of after this program.
Signature
Student Name:
*
Date:
*
-
Month
-
Day
Year
Date
Parent/Guardian Name (Please Print)
*
Parent/Guardian Signature
*
Revised August 25, 2025
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