Temporary Guardian Designation Form

Temporary Guardian Designation & Emergency Medical Authorization

"*" indicates required fields

To be completed by any parent or legal guardian whose child is attending programs at the Ashokan Center without them.

Emergency Contact Policy: If your child requires a doctor or hospital, it is the Ashokan Center’s policy to first call the parent, then the Emergency Contact people if the parent cannot be reached. If neither the parent nor contact people can be reached, this signed authorization form will allow treatment to be secured by a designated On-Site Guardian.

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User Role

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Page Embed

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Product Type

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Admin

admin

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Type*

Student

Chaperone

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Add-on

Product

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Event name

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Event Name*

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Start Date

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End Date

Name of Person filling out this form

First Last

Email of the person filling out this form

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Upload Signed Waivers

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Max. file size: 50 MB.

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Upload Additional Forms

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Event Name & Dates

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Event ID

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Event Dates*

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Registration ID*

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Parent Name*

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Parent Email*

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Medical Coordinator Email

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Trip Type*

Parent/Legal Guardian Information

Your Name*

First Last

Your Email*

Your Phone

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Second Parent Name*

First Last

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Second Parent Email*

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Second Parent Phone

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Minor Attendee Information

Attendee Name as it appears on Birth Certificate (Legal Name)*

First Last

Preferred Name if different then above

Gender*

Male

Female

Nonbinary

Pronoun

Minor Attendee Birthday*

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Grade

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Age

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Age at time of event

Medical Info

Family Physician*

Physician Phone*

Physician Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Provider*

Insurance ID*

Health History*

Other Health History info

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Dietary Needs

Gluten Free

Dairy Free

Vegetarian

No Red Meat

Does your child have any of the following?

Dietary Restrictions

Food and/or Drug Allergies

Severe allergies unrelated to food and drug

This student is currently taking medications

Dietary Restrictions?*

Does your child have any food allergies or restrictions?

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Admin Dietary Restrictions

Does your child have any food allergies or restrictions?

Food/Drug Allergies*

Please offer as much detail as possible.

Severe allergies unrelated to food and drug*

Please offer as much detail as possible.

What medications does your child currently take*

Please provide the following for each: Name of Medication, How taken (orally, topically, etc.) Dosage How Often (frequency including time of day)

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Medication List Array

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Admin Health Status

Awaiting Review

In-Progress

Incomplete

Completed

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Admin Form Return

Medication and OTC Form

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Admin Rescue Meds

Epi Pen

Inhaler

Seizure Medication

Emergency Contacts

Emergency Contact 1 Name*

First Last

Emergency Contact 1 Phone*

Emergency Contact 1 Relationship to Child*

Emergency Contact 2 Name*

First Last

Emergency Contact 2 Phone*

Emergency Contact 2 Relationship to Child*

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Emergency Contact*

Please submit at least one contact name & phone number to be used in an emergency.

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Admin Notes

Temporary Guardian Designation

My child will be attending the program or event above at the Ashokan Center 477 Beaverkill Rd Olivebridge, NY 12461.

I hereby authorize the following person to act as my child’s Temporary Guardian. They will take full responsibility on my behalf for supervising my child & have my permission to make decisions pertaining to emergency medical care in the event that I cannot be reached.

Temporary Guardian Name

First Last

Phone

General Waivers

Authorization to Consent to treatment of a minor temporarily separated from his/her parents:*

I, the undersigned, parent or legal guardian of this child, a minor, am familiar with the program and the general nature of activities planned during their trip to The Ashokan Center, and to the best of my knowledge the above information is correct. My child is capable of participating in and has permission to engage in all activities. I do hereby authorize the above designated Temporary Guardian as our agent(s) to consent to any diagnostic procedure or medical care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician at the nearest hospital with facilities appropriate to my child’s injury/illness. This authorization shall remain effective for the duration of the event.

Student Waiver of Liability*

I hereby accept any and all responsibility for, and assume the risk of any and all injury or damage to my dependent children which might arise directly or indirectly as a result of, and or participation in, the Ashokan Center’s program. I hereby expressly release, discharge and hold harmless from any liability whatsoever the Ashokan Center and all employees and volunteers in their capacities as representatives of The Ashokan Center. Except for injuries caused intentionally, or by willful misconduct, I certify that I am familiar with the contents of this release, that I have read and understand the same, and that it is my intention by signing this release that the same is binding not only of me, but my heirs, administrators, executors, successors and assigns.

Media and Testimonial Release*

I authorize the Ashokan Center to photograph and/or film my child during their Ashokan trip. I further authorize the use of the photo/video content for the furthering of the Ashokan Center’s nonprofit mission, ie: grant applications, marketing materials, website.

Photo/video of my child may be shared only in a privately linked trip gallery page.

I do not consent to my child being photographed.

Contact Opt-In*

I consent to being contacted by the Ashokan Center via email, phone, or mail. I may remove myself at any time.

Yes

Not at this time

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Roster ID

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Roster id

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Bunk ID

Signature*

Comments

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Will this child need medication while they're here?

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The Medication Authorization Form is required only if a student needs to take ANY type of medication. This form or a similar one from your doctor's office, must list specific medications, the dose, the route, and the time administered for each and every medication in order for us to legally administer them. This also applies to any OTC medications, including the seven we keep in stock here (Ibuprofen, Acetaminophen, Benadryl (both oral and topical cream), loratadine (Claritin), antibiotic cream and hydrocortisone ointment).

The Medication Authorization Form requires both the parent or legal guardian’s signature as well as the Dr.’s signature and stamp.
English: Click here to download Medication Permission Form (optional)
Spanish: Click here to download Medication Permission Form (optional)
We can also accept a form provided by your physician

I would like to bypass uploading the Medical Authorization form at this time. I am aware that Ashokan Center can not provide my child over-the-counter medications (Tylenol, Benadryl, etc.) without this Medical Authorization Form. I am aware that Ashokan cannot administer prescription medication without this Medical Authorization form.

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Medication Requirements*

All prescription medications must be in their original labeled pharmacy containers. All OTC medications must be new, unopened in their original containers and be within their expiration date.

Any loose, unmarked medications provided in ziplock bags or weekly pill dispensers will not be accepted and will be immediately returned to school staff.

I acknowledge that Ashokan can not legally dispense any medication that does not comply with the requirements above.

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Med Form(s) Requirements*

Med Form(s) must:

list specific medications, the dose, the route, and the time administered for each and every medication.
This also applies to any OTC medications, including the seven we keep in stock here- (Ibuprofen, Acetaminophen, Benadryl (both oral and topical cream), loratadine (Claritin), antibiotic cream and hydrocortisone ointment.
Include the prescriber’s signature and stamp as well as the parent’s signature granting us permission to administer.
Be less than one fiscal year old.

I acknowlede that the forms being uploaded comply with the requirements above

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Please Upload Medical Authorization Form for use of prescribed and over-the-counter medications

PLEASE NOTE: YOU MAY USE THE RED “SAVE AND CONTINUE LATER” LINK AT THE BOTTOM OF THIS PAGE IF YOU ARE UNABLE TO COMPLETE THE MED FORM AT THIS TIME. (IF YOU USE THIS FEATURE, YOU WILL BE ASKED TO PROVIDE AN EMAIL IN ORDER TO RECEIVE A LINK).

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Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB.

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School Nurse Med Form Review

Not Reviewed

Needs Further Review

Approved

CAPTCHA

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School Med Notes

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Public Comment

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Activity Sheet Comment

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Educator Comment

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OTC Medictions Recieved

Comments

This field is for validation purposes and should be left unchanged.