Cadet Consent For Medical Treatment (Page 5 of 6) in pdf

VALLEY FORGE MILITARY ACADEMY & COLLEGE

Cadet’s Name________________________________

Date of Birth ________________________________

HEALTH INSURANCE

Please include a front and back copy of your medical, dental and prescription

insurance cards for Cadet’s medical records.

Please check which services are covered under the insurance information listed below:

Medical

Prescription

Dental

Name of Insurance Carrier:___________________________________________ Is this an HMO?

Yes

Company Address: _____________________________________ Phone:_____________________________________

Policy and Group Numbers: _____________________________ Policy Holder’s Name: _______________________

Policy Holder’s Date of Birth:____________________________ Policy Holder’s Employer:____________________

Policy Holder’s Social Security Number: ______________________________________________________________

ACADEMY MEDICATION MANAGEMENT PROGRAM

VFMAC Health Center staff will maintain possession of all prescription and nonprescription medications for the Academy Cadets while they are in

residence. Academy Cadets will receive medications from the Health Center staff daily.

THE HEALTH CENTER STAFF will be responsible for the following:

•

The Nurse will distribute medication to Academy Cadets Sunday through Saturday.

•

Reporting to Tactical, Academic, and Counseling departments the Cadet’s medication compliance daily.

•

Will complete laboratory tests as ordered in writing from prescribing physician.

•

The Health Center will retain medications for one week at the completion of the school year or from your Cadets departure. Arrangements for disposition

must be made or medications will be destroyed.

ACADEMY CADETS will be responsible for the following:

•

Report to the Nurse for all their prescribed medications and vitamins.

•

Be subject to disciplinary action due to medication non-compliance.

•

Cadets may report to the Health Center staff any side effects, dosage issues, or concerns they have in regards to their medications.

PARENTS/GUARDIANS will be responsible for the following:

•

Do not send any supplements, vitamins, or any medications directly to an Academy Cadet.

•

All Academy Cadet medication must be sent to the Health Center directly.

•

Must provide permission in writing, email (HealthCenter@vfmac.edu), or via phone (610-989-1517/1518) to the Health Center in order to release

medication directly to any minor (under age 18 yrs) Cadet for any scheduled leave periods.

•

Acknowledge the Medication Management Program Policy. Please consult the fee schedule for charges pertaining to Medication Management

Program.

•

Send prescription directly to Babis Pharmacy or Health Center.

•

Send co-pay directly to Babis Pharmacy.

•

I give permission to have my son’s medication sent on an off campus event. The medication will be sent with the coach, athletic trainer, teacher, chaperone,

counselor, or his/her designee and will be dispensed by them.

“I hereby release, discharge and agree to indemnify and hold harmless the VFMA&C, its agents and employees from any and all claims, suits

or demands of any kind whatsoever including negligent conduct made either by me or in behalf of the said Cadet with respect to the

administration of medication to include vitamins, supplements, energy drinks, protein shakes, etc. to such Cadet. It is my intention that

neither VFMA&C employees nor any of its agents shall be accountable for any adverse consequences of any kind whatsoever arising out of

the administration of medication.”

_____________________________________

__________________________________

PARENT OR GUARDIAN’S SIGNATURE

CADET SIGNATURE (if age 18 or older)

________________________________________________________

____________________________________________________