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Microsoft word - junior staff forms 2008

Please return this form by May 23, 2008 to: (Please type or print legibly)
Travel Information Participant wil arrive at the HOBY Leadership Seminar by: CAR If traveling by car, participant will be driven by (name of driver): _______________ OR ___ Participant wil be driving him/herself to the seminar. Note: Participants that drive themselves to the seminar are required to surrender their car keys upon arrival; they wil be returned at the conclusion of the seminar. Parents: HOBY strongly discourages students from driving themselves to and from the seminar; students are typical y very tired by the end of the weekend. If traveling by bus, train, or plane – Name of Carrier: How will student be transported between bus/airport/train station and seminar facility? If departure plans are different, please explain: If departing by bus, train, or plane – Name of Carrier: Departure Date: ___________________ Departure Time: I UNDERSTAND THAT ALL TRANSPORTATION TO AND FROM THE SEMINAR FACILITY IS MY RESPONSIBILITY. THIS INCLUDES RESPONSIBILITY FOR MY SON OR DAUGHTER DURING ANY CONNECTION FLIGHTS, BUS TRANSFERS, OR IN BETWEEN MODES OF TRANSPORTATION.  Signature of Parent/Legal Guardian: _____________ Date: _____________________ Please return this form by May 23, 2008 to: (Please type or print legibly)
Dear Participant: For our records, and for your protection, please have your parent or legal guardian complete this form in its entirety. Please provide ALL requested information and obtain the signature of your parent or legal guardian. High school/Institution participant represents Participant’s permanent street address Please check the fol owing diseases the participant has had in the past: Check the fol owing conditions the participant has had or are subject to now: What treatments or medications (if any) does the participant require for any of the above conditions? Has the participant ever been hospitalized or had serious il nesses? If so, please explain in detail; use additional sheet if necessary. If there are any limitations on the amount of physical exercise the participant can engage in, please describe and explain (use additional sheet of paper if necessary): Please list al al ergies (insect stings, plants, foods, etc.) and any dietary needs or restrictions, including vegetarianism. Please list any medications the participant has al ergic reactions to (penicil in, sulfa drugs, tetnus antioxin, etc.) and what the reaction is: Please list any prescription medications the participant is taking, including: (1) name and type of medication; (2) condition for which medication is being prescribed; and (3) dosage information. Please also list any non-prescription medication the participant takes regularly. Please read HOBY’s Policy for Use of Medication During a HOBY Event and have the participant bring a doctor’s note or completed Medication Verification Form for Physicians to the seminar. By signing this form, you attest that the use of the medication wil not impair the participant’s ability to care for his/her own safety or the safety of others; increase the risk of harm to others; or cause dizziness and/or fatigue. Please mark the below over-the-counter medications that you approve to be administered to your child by HOBY: decongestant (please specify if a specific antibiotic ointment (such as Neosporin, Polysporin, eye drops (such as artificial tears or saline) IMMUNIZATIONS Please list the type of il ness the participant has received immunizations for: Tetanus booster (Please indicate date of last booster) I verify that all information provided in this Medical History Records Form is complete and accurate. I hereby give my permission to HOBY to store the above prescription medication listed to my child. I understand and have discussed with my child that it is the responsibility of my child to take the medication as directed by his or her physician while at a HOBY event. I also give permission for HOBY to administer over-the-counter medications that I have approved above that may be necessary to treat minor conditions. I understand that if HOBY deems necessary, they wil take my child to a hospital or other medical facility for more intensive treatment. I understand that al HOBY staff, volunteers and HOBY, as an organization, are not liable for any adverse affects that may occur due to this medication and they are not liable in the possibility that a child misses a prescribed dose or in the event the medication is administered incorrectly. I also state that al the above information is complete and accurate and any misapplication of medication due to inaccurate, incomplete, or unreadable information is not the responsibility of HOBY. I also understand that the HOBY staff, volunteers and HOBY, as an organization, are not responsible if my child fails to present themselves at the announced places/times to take the above specified medication.  Signature of Parent/Legal Guardian: Policy for Use of Medication During a HOBY Event If a minor or adult participant is required to take medication during a HOBY event, including the HOBY Leadership Seminar, he/she must comply with the following guidelines: 1. HOBY volunteers wil not dispense prescription medication for participants during the event. 2. Any participant bringing prescription medication to the event must submit a doctor’s note or completed Physician Medication Verification Form to HOBY, preferably in advance or at the event check-in, detailing the following: b. The condition for which the medication is being prescribed. c. Dosage information. d. Attestation that use of the medication wil not impair the participant’s ability to care for his/her own safety or the safety of others; increase the risk of harm to others; or cause dizziness and/or fatigue. This information is necessary to provide medical personnel in the case of emergency and the participant is unable to communicate the information. Al prescription medication must be submitted to HOBY in its original container as labeled by the pharmacy. HOBY wil store required medications in a locked facility. The medications a participant may be al owed to keep in his/her possession is any asthma medications (inhalers, oral steroids, etc.), birth control pil s, acne medication, any topical medications, al ergy medications, medications for treatment of diabetes (insulin, etc.) and EpiPens, as wel as any other prescription medication required by the doctor to be in their possession at al times. But there wil need to be a doctor’s note completed and on file for al medication brought to the event, whether stored or not. If a participant fails to advise HOBY that he/she is taking prescription medication, is not taking the medication as prescribed, and/or has stopped taking prescription medication, HOBY reserves the right to send the participant home at the participant’s guardian or parent’s expense. 3. If the participant has a medical condition that requires any assistance, the assistance must be provided or contracted directly by the participant or his/her parent/guardian. Under no circumstances wil a HOBY volunteer help with dispensing medication. If help is needed on an emergency basis, emergency personnel wil be contacted. 4. Proper administration and dosage of medication shal be the sole responsibility of the participant. HOBY wil have no responsibility in seeing that the participant takes the medication as prescribed by the doctor. 5. Participants should only bring as much medication as wil reasonably be needed during the event. 6. Participants are prohibited from sharing their personal medication with another participant. Conversely, participants are prohibited from accepting medication from anyone, other than HOBY medical staff. 7. Any participant bringing il egal drugs, narcotics, misused prescription drugs and/or mood altering substances or alcoholic beverages to a HOBY event, using them on HOBY premises or dispensing or sel ing them on HOBY premises wil be subject to disciplinary action, including automatic expulsion from the event. The discharged participant wil be responsible for any charges/fees incurred as a result of leaving the event early (i.e. change in airfare, taxi, etc.). HOBY has a very strict/no-tolerance policy when it comes to drugs. Please return this form by May 23, 2008 to: Medication Verification Form for Physicians (Please type or print legibly)
(This form is to be completed by the participant’s prescribing physician. If the participant has more than one prescribing physician, then each physician will need to complete a form. Please type or print legibly.) 1. Name of Participant/Patient: ____________________________________________________________________________________ 2. Prescribing Physician Name: 3. Prescribing Physician Medical License Number and State where licensed: 4. Please complete the chart below for the medications which you have prescribed to the participant. 5. Please affix physician’s business card or voided prescription in the space below. As the prescribing physician, I attest that the use of the medications prescribed by me, and taken as directed as listed above, should not impair the participant's ability to care for his/her own safety or the safety of others; increase the risk of harm to others; or cause dizziness and/or fatigue.  Signature of Prescribing Physician: Please return this form by May 23, 2008 to: 1. Name of Participant: ______________________________________________________________ 2. Health insurance plan name: ________________________________________________________ 3. Health insurance plan number: ______________________________________________________ 4. Health insurance group number: _____________________________________________________ 5. Check here ______ if participant is not covered by a health insurance plan. 6. Name of parent or legal guardian: _____________________________________________________ 7. Emergency contact telephone number: _________________________________  Signature of Parent/Legal Guardian: Please return this form by May 23, 2008 to: Consent & Acknowledgement of Risk Form (Please type or print legibly)
Event/Activities: Iowa HOBY Leadership Seminar Dates: Friday, June 6 to Sunday, June 8, 2008 Location: Graceland University in Lamoni, Iowa IN CONSIDERATION of the right to attend and participate in the Activities described above, the Participant (and, if the Participant is a minor, his or her parent or legal guardian) hereby: 1) Agrees to abide by al rules and regulations established by Hugh O’Brian Youth Leadership (HOBY); 2) Authorizes HOBY or any of its agents to provide, obtain, or authorize any reasonable incidental and/or emergency medical treatment for the Participant, in the event of the Participant’s il ness, injury, or incapacity, and hereby accepts the responsibility to pay for such treatment; 3) Grants to HOBY for any purpose connected with promoting the purposes and goals of HOBY, but not for commercial exploitation, the right to use the Participant’s name, voice, and likeness in any writings, photographs, films, and recordings of the Participant while he or she is participating in the Activities, and any biographical information submitted by the Participant to HOBY, and to use, reproduce, publish, and distribute the same; 4) Acknowledges that there is an element of risk involved in any activity involving travel outside of one’s own home or community; certifies that the Participant is physical y, mental y, and emotional y capable of attending and participating in the Activities; assumes al risk of and financial responsibility for any loss or injury to the Participant or others that may occur as a result of the Participant’s negligence or misconduct; and indemnifies and holds HOBY harmless from and against any and al costs, claims, demands, charges, liabilities, obligations, judgments, executions, costs of the suit and actual atorneys’ fees incurred or suffered by HOBY as a result of, or arising out of, the Participant’s negilgence or misconduct; 5) Agrees to immediately advise in writing the person in charge of the HOBY event and/or HOBY International of any injury, il ness, or loss that occurs 6) This Consent and Ackowledgment of Risk shal not be amended, supplemented, or abrogated without the written consent of HOBY’s International 7) The Participant (and, if the participant is a minor, his or her parent or legal guardian) has read this Consent and Acknowledgment of Risk, and IF PARTICIPANT IS A MINOR, SIGNATURE OF HIS OR HER PARENT/LEGAL GUARDIAN IS REQUIRED: Name of Parent/Legal Guardian:  Signature of Parent/Legal Guardian: before me the undersigned, a Notary Public in and for said , personal y known to me, or proved to me on the basis of satisfactory evidence, to be the person whose name is subscribed to the within instrument and acknowledged that executed the same. Please return this form by May 23, 2008 to: WE PROVIDE THIS NOTICE TO DESCRIBE HOW MEDICAL INFORMATION ABOUT YOUR CHILD OR DEPENDENT MAY BE USED AND DISCLOSED. PLEASE REVIEW THE BELOW INFORMATION CAREFULLY AND IF YOU AGREE, PLEASE EXECUTE THE ATTACHED AUTHORIZATION. We understand the importance of privacy and are committed to maintaining the confidentiality of your child or dependent’s medical information. We may preserve the medical disclosure information (“medical information”) concerning your child or dependent provided by you to HOBY for up to seven years. We use and retain these records to provide or enable health care providers to provide quality medical care to your child or dependent in the event of an emergency. This notice describes how we may use and disclose your child or dependent’s medical information. It also describes your rights, the rights of your child or dependent, and our legal obligations with respect to your child or dependent’s medical information. A. How HOBY May Use Or Disclose Your Child Or Dependent’s Medical Information HOBY col ects health information about your minor child or dependent and stores it in a file and on a computer. These files are the property of HOBY, but the information belongs to you and your child or dependent. The law permits us to use or disclose your child or dependent’s medical information for the fol owing purposes: 1. Treatment. In the event of an emergency, we wil provide medical information about your child or dependent to the appropriate health care provider to provide for the medical care of your child or dependent. We may also disclose medical information to members of your family or others who can help your child or dependent if you are not available. 2. Awareness. We may also provide medical information about your child or dependent to HOBY employees and/or volunteers to the extent necessary. 3. Alumni Activities. We may provide medical information about your child or dependent to HOBY employees and/or volunteers in connection with alumni activities or events in which your child or dependent may be a participant. 4. Limited Disclosure. We wil limit the use and disclose of medical information about your child or dependent as detailed below. When HOBY May Not Use Or Disclose Medical Information Except as described in this Notice of Privacy Practices, HOBY wil not use or disclose health information which identifies your child or dependent without your written authorization. 1. Request for Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information by way of a written request specifying what information you want to limit and what limitations on our use or disclosure of that information you wish to have imposed. We reserve the right to accept or reject your request and wil notify you of our decision. 2. Copy of Notice. You have a right to a paper copy of this Notice of Privacy Practices. If you would like to have a more detailed explanation of these rights, or if you would like to exercise one or more of these rights, contact Hugh O’Brian Youth Leadership at (310) 474-4370. Changes to this Notice of Privacy Practices We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections wil apply to al protected health information that we maintain, regardless of when it was created or received. Questions or complaints about this Notice of Privacy or how HOBY maintains the medical information of your child or dependent should be directed to Hugh O’Brian Youth Leadership at (310) 474-4370. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I received a copy of the Notice of Privacy Practices.  Signature of Parent/Legal Guardian:

Source: http://www.iahoby.org/seminar/2008/documents/Junior%20Staff%20Forms%202008.pdf

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