If yes, fill out additional medication form.
This health history is correct so far as I know, and I give my full consent for the applicant to attend Spina Bifida of Louisiana (SBLa) Family Conference and to engage in all prescribed activities, excepted as noted by me.
In consideration of participation in the program and for the general purposes of the Kids’Camp, specifically including, but not limited to, the community service afforded by the availability of the program to children with disabilities, I agree to indemnify and hold harmless SBLa from and against any injury or loss which my child may suffer arising out of or related to the following:
1. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the Conference Committee to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child as named above;
2. The administration of physician prescribed medication. Prescribed medication will be administered ONLY if the medication is in its original container labeled with the physician's instructions for its use accompanied by a written statement by the child's parent or guardian as to the time of day the specific (please state name of) medication is to be given;
3. The catheterization of a child will be carried out by non-professional but medically trained Kids’Camp personnel ONLY with written instructions by the child's parent or guardian as to the time of such needed catheterization;
4. Conference committee will make the final determination whether a child may participate in Kids’Camp activities.
Permission is given for your child to receive first aid for minor injuries, administration of prescription medications according to physician’s orders and emergency care/transport for life threatening conditions.
In addition, permission is granted to SBLa to photograph videotape or record my child for the purpose of the media or for SBLa publications.