Form 3-2525 Native Youth Community Adaptation and Leadership Congres

FWS Form 3-2525 (Rev. 07/2020) OMB Control No. 1018-0176

U.S. Department of the Interior Expires 02/29/2024

Native Youth Community Adaptation and Leadership Congress

Student Medical Information

(Please Print Clearly)

Student’s Preferred

Student’s Full Name: Name/Nickname: _________________________

Date of Birth: Age: _______

Is your child covered by Public Health Insurance? (i.e. Medicaid, CHIP or Indian Health Service (IHS)) Yes No

If yes, name of public health insurance: _______________________________________________________________

Is your child covered by private health insurance? Yes No

If yes, name of child’s health insurance provider: _______________________________________________________

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Policy Holder’s Name Insurance Policy Number

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Group or Member Number Prescription Card Number

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Provider Name Doctor/Provider’s Phone Number

Medical Information

Please List All Medications Required by Student (Both Prescription and Non-Prescription):

_____________________________________ __________________________ ___________________________

Medication Dose Frequency

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Medication Dose Frequency

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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) ____________________________________________________________

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: __________________________________________________________________

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List Student Food Allergies: __________________________________________________________________________

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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.

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Print Parent/Guardian Name Parent/Guardian Signature Date

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Parent/Guardian Emergency Phone Number

NOTICES

PRIVACY ACT STATEMENT

Authority: The information requested is authorized by the Government Organization & Employee Training Act (5 U.S.C. 4101, et seq.), Executive Order 11348 (Providing for Further Training of Government Employees), Americans with Disabilities Act and the E-Government Act of 2002, (42 U.S.C. 112101) and the E-government Act of 2002 (44 U.S.C. 3501).

Purpose: To enroll students for National Conservation Training Center (NCTC) hosted programs.

Routine Uses: The information on this form may be used by program leaders to contact those selected for the NYCALC program. Information may be disclosed to the Department of Justice (DOJ), a court, adjudicative or other administrative body, the fiscally sponsoring organization or agency of the student, a party in litigation before a court or adjudicative or administrative body; or any DOI employee when represented by DOI or DOJ for legal proceedings or as required by law pursuant to the routine uses identified in the System of Records Notice: DOI Learn, Interior – DOI-16.

Disclosure: Providing the requested information is voluntary. However, failure to provide the information may prevent participation in the program.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501 et seq.), the U.S. Fish and Wildlife Service collects information 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 1018-0176.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information to average 30 minutes, including time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 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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