Anytown 2026 Delegate Medical Form 

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Anytown
Anytown will be a week of growth and learning for all students. The topics discussed in the program empower and better prepare youth to be empathetic leaders. It’s important that applicants are aware that some of the topics discussed in the program may be challenging (social justice topics such as race, racism, gender, privilege, etc). Our staff is trained and qualified to assist our students. Please fill out this form in detail so we can do that to the best of our ability.  

To fill out this form, you will need name and phone number of your emergency contacts, immunization information, current medications (if applicable), and health insurance information (if applicable).

If you select yes to having allergies, asthma, taking medication, or seeing a therapist then you will see additional questions about these medical conditions. 

Should you need assistance completing this application please contact Kelly Dawson at kdawson@nccjtriad.org or (336) 272-0359 x 210 .

Privacy Note: Your medical information will be stored on this encrypted form. Medical and mental health staff and NCCJ Program Directors will be the only people who have access to your medical information while at Anytown. Sensitive medical information is deleted and/or destroyed in August at the close of the Anytown season. 
Health History and Medical Release Form

All medical information will be kept strictly confidential.


This section should be completed with a parent or guardian.

Student Information





Parent /Guardian #1



Parent /Guardian #2



Additional Emergency Contact Info



Medical Conditions and History

















Other Experiences


Medications







Over the Counter Medication Administration

Next Page: Immunizations, Dietary Restrictions, Health Insurance, and Consent to Treat

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Immunizations

Dietary Restrictions
Food cannot be prepared to order. However, the Blowing Rock Conference Center staff accomodate dietary requests to the best of their ability.  (They do not have a kosher or halal kitchen.)


Health Insurance












Permission to Provide Necessary Treatment or Emergency Care
In the event of an accident or illness that requires emergency medical care, I give permission to the attending licensed medical staff to give medical attention as appropriate for the health and safety of my child/the child in my care. I’m aware that the medical staff may make the decision to take my child/the child under my care to the nearest medical facility to secure and administer treatment, including hospitalization.


Parent/Guardian Authorization
This health history is correct and complete as far as I know, and my child/the child in my care has permission to participate in the program activities except as noted.  I also understand that NCCJ, its officers, board members, volunteers, agents, employees and licensees cannot be held liable for any health complications or problems that resulted from or were caused by my child's/the child in my care's negligent regard for their own health and safety.


Delegate Agreement to Abide by Health Restrictions
I understand and agree to obey the restrictions placed on my activities during this program. I agree not to violate on the safety or consciously cause bodily harm to the others in attendance at Anytown. I also understand that NCCJ, its officers, board and staff members, and volunteers cannot be held responsible for any health complications or problems that resulted from or were caused by my irresponsible regard for my own health and safety.