GARDEN STATE LACROSSE CAMP

1345 Easton Avenue, Somerset NJ 08873

MEDICAL WAIVER

Please list any allergies or medical concerns we should be aware of. *
Medications
• All medications, prescription or over-the-counter, must be administered through our nurse's office and brought to the nurse's office by a responsible adult. • Medication shall be in the original labeled container with the medication form signed by the parent and medical provider. • Medication forms, which shall include the child's name, medication, dose, route and time, area available through the nurse's office and are required for the medication to be administered during your child's program. You may use this past school year's forms.
 
I certify my child is in good health and may participate in all program activities unless noted above. I give consent for my child to receive first aid treatment, which include, but are not limited to oral pain reliever, lip ointment, topical anti-itch liquid, contact lens solution, topical insect sting relief, first aid ointment, emergency epinephrine and diphenhydramine (Benadryl). If, in the judgment of any representative of Rutgers Preparatory school, my child should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment be given to my child by the nurse or school representative. I give consent for my child's health information to be shared with school faculty, staff and emergency care personnel on a 'need to know basis'.
 
I agree to indemnify and hold harmless Rutgers Preparatory School, its trustees, officers, agents and employees from and against any and all claims or causes of action of any kind or nature whatsoever, and expenses, including attorneys' fees, arising or claimed to have arisen out of any injuries or damages sustained by my child or me, regardless of cause (including negligence on the part of any person identified above) and any injuries or damages received or sustained by Rutgers Preparatory School or any other person or persons or property, as a result of intentional or negligent acts or omissions of my child.
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