January 1

Youth Program Medical Form

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This information is required by Williston Northampton School to ensure your child’s safety. Even if you plan to stay overnight, it’s important that we create the safest environment possible for your child in case we can’t reach you. This information will be stored in a binder for the director of the Youth Program and the only two people to view it will be the program director for SWB (Julie Lyonn Lieberman) and the director for the Youth Program (Alissa Jackson).

Thank you for your understanding.

Strings Without Boundaries MEDICAL FORM

  • This address form might confuse you because it provides a box for the address below the word “Address” but the zip code should go in the box above the phrase “zip code.” So much for automated technology… Well, at least you don’t have to fill out a form by hand!
  • Number each medical condition to create an easy-to-read list. Or type “none.”
  • Please list any medications that may need to be administered during the camp along with instructions for administration. Here is an example: 1. antibiotic (name of antibiotic): 1 pill after breakfast, 1 after dinner. 2. Asthma medication (name of medication): Only to be used when needed. Etc. OR TYPE “NONE”
  • Medical Treatment Consent for Minors:

    Medical Treatment Consent for Minors If your child will be under age 18 while at Strings Without Boundaries on the Williston Northampton School campus. It is camp policy to secure your consent for medical treatment or medication distribution and for the use of medical devices. All medications must be in a medicine bottle and labeled with the camper’s name, doctor’s name and phone number, medication name, and dosage. Also, please complete the following for each medication: Emergency medications such as inhalers, bee sting kits, or insulin may be kept with the student. All other medications will be stored by the director of the Youth Program or, if you’re staying overnight with your child, you will keep it in the shared dorm room.
  • I understand that typing my name where indicated will carry the same legal weight as a signature.
  • MM slash DD slash YYYY


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