Native Youth Community Adaptation and Leadership Congres

OMB Control No. 1018-####
Expiration Date: ##/##/20##

FWS Form 3-2525 (Rev. 07/2020)
U.S. Department of the Interior

Native Youth Community Adaptation and Leadership Congress
Student Medical Information
Print Clearly

Student’s Preferred
Name/Nickname:

Student’s Full Name:
Date of Birth:

Age:

Is your child covered by Public Health Insurance? ____ Yes ____ No
(i.e. Medicaid, CHIP or Indian Health Service (IHS)
If yes, name of public health insurance:
Is your child covered by private health insurance? ____ Yes
If yes, name of child’s health insurance provider:

____ No

Policy Holder’s Name

Insurance Policy Number

Group or Member Number

Prescription Card Number

Student’s Home Doctor/Other Provider Name

Doctor/Provider’s Phone Number

Medical Information:
List Medications Required by Student (both Prescription and Non-Prescription
Medication

Dose

Frequency

Medication

Dose

Frequency

Medication

Dose

Frequency

My child is aware that they may not share any medication with other campers.
Participant Initials:_________
Drug sensitivities/allergies (circle if severe) _______________________________________
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OMB Control No. 1018-####
Expiration Date: ##/##/20##

FWS Form 3-2525 (Rev. 07/2020)
U.S. Department of the Interior

Epi-pen: Does your child require an Epi-pen to treat an allergy? ____Yes

____No

If yes, please make sure to send at least two Epi-pens along with your child.
Asthma: Does your child use an inhaler for asthma?
____ Yes
____No
If yes, my child has been instructed to carry their inhaler to ALL camp activities. Initial
Tetanus: Date of last tetanus

Pre-existing conditions:
Does your child have any injuries or conditions that presently exist that would limit them
from any physical activities?
____ Yes
____ No
If yes, describe
Has your child had any sports or orthopedic (muscle, joint, etc) injury within the past year?
____Yes ____No

If yes, describe

Does your child have any emotional health or behavioral issues?

____ Yes

____ No

If yes, explain

Has your child been diagnosed with any other significant chronic illness (diabetes, heart,
epilepsy, etc?)
____ Yes
____ No
If yes, describe
Is participant currently pregnant or has she been pregnant within the past year?
____Yes ____ No

If yes, list dates

Other Health information will not be shared except with medical practitioners, should
circumstances warrant. For example, include for your child any recent hospitalizations,
injuries, illness, infectious diseases, or any chronic or recurring illness or conditions such
as allergies:

List Student Food Allergies:__________________________________________________
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OMB Control No. 1018-####
Expiration Date: ##/##/20##

FWS Form 3-2525 (Rev. 07/2020)
U.S. Department of the Interior

Prescription Medications Statement:
ALL student medications will be registered and handed to the NYCALC Health Care
Coordinator/Nurse upon arrival. Prescription and over-the-counter medications are only
dispensed by the Nurse or designated staff members. All medications must be given to the
Nurse upon arrival at the National Conservation Training Center (NCTC). Students are
allowed to keep vitamins, topical creams, inhalers for asthma, and Epi-pens in their room.
Over-the-Counter Medicines Available at NCTC as needed:
The following list are examples of over-the-counter medications that may be made available
to students at NCTC as deemed appropriate by the nurse:
Acetaminophen (Tylenol); Bio Freeze (muscle pain relief); Blistex; Calamine Lotion;
Chloraseptic; Cough Drops; DayTime Cold & Flu; Diphenhydramine (Benadryl); Epinephrine
(Epi Pen); Guiafenessen (Robitussen); Hydrocortisone Cream; Ibuprofen (Advil); Immodium
AD (diarrhea relief); Ivy Rid (Benzocaine); Loratadine (Claritin/Claritin D); Maalox; Milk of
Magnesia; Naproxen Sodium (Aleve); NightTime Cold & Flu; Pepto-Bismol; Pseudoephedrine
HCL (Sudafed); Silver Sulfadiazine (Burn Ointment); Super Blue Stuff (Sore Muscles,
Bruises, Sprains); Tolnaftate - Tinactin (to treat athlete’s foot fungus); Triple Antibiotic
Ointment (to treat scrapes to prevent infection)
In the event that I, the child’s parent/guardian, cannot be reached in case of a medical
emergency, I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia and
other medical and/or hospital procedures as may be performed or prescribed by the attending
physician and/or paramedics for my child and waive my right to informed consent of
treatment.
I give permission for my child to be treated for minor scraps, bruises, cuts, and skin irritations
by National Conservation Training Center staff and the use of over-the-counter medicines.

Print Parent/Guardian Name

Parent/Guardian Signature

Date

___________________________________________
Parent/Guardian Emergency Phone Number
Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C.
3501) to assure the health and safety of participants while on site at the National Conservation Training Center for the Congress.
Your response is voluntary and we will not share your response publicly. We may not conduct or sponsor and you are not
required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and
approved this focus group and assigned OMB Control Number 1018-####.
Estimated Burden Statement: We estimate it will take 30 minutes to complete this form, including time to read instructions and
gather information. You may submit comments on any aspect of this information collection to the Service Information Collection
Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via
email at [email protected]. Please do not send your completed form to this address.

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