Parental Consent And Release Of Liability Agreement Page 5
Download a blank fillable Parental Consent And Release Of Liability Agreement in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Parental Consent And Release Of Liability Agreement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5PERMISSION TO DISPENSE MEDICATIONS
Participant’s Name: _________________________________________ DATE: ____________________
Champions Swim and Travel Experience staff will not dispense non-prescription (Advil, etc.) or
prescription medication (antibiotics, insulin, inhalers, etc.) to the above named participant until the
following information has been completed by a parent or guardian. I understand it is the
parent’s/guardian’s responsibility to give the medication directly to the camp director or designated staff
member in individual dosage containers, original prescriptions containers, or envelopes clearly labeled
with dosage instructions on the first day of camp. In all cases, the recommended dosage of any over-the-
counter medication will be adhered to according to the manufacturer’s instructions and the recommended
dosage of any prescription medication will be adhered to according to the following instructions:
I ________________________________, the parent/guardian of ________________________________
give permission to the staff of Champions Swim and Travel Experience to administer to my child:
Prescription Medication: ________________________________________________________________
Dosage: _______________________________ Dispensing Time: _______________________________
Special Instructions: ____________________________________________________________________
Prescription Medication: ________________________________________________________________
Dosage: _______________________________ Dispensing Time: _______________________________
Special Instructions: ____________________________________________________________________
NON-PRESCRIPTION MEDICATIONS:
Ibuprofen (Advil) YES NO; Acetaminophen (Tylenol) YES NO;
Antacids / Anti-Nausea: Maalox YES NO; Throat / Cough Lozenges: Cepacol YES NO;
Allergies: BenadrylYESNO
Other Non-prescription Medicine which may be administered:
_____________________________________________________________________________________
My child may possess and self administer the following medicine: _______________________________,
and I affirm that my child understands and agrees that he/she will use the medication only according to
dosage instructions, and will not share or otherwise provide medication to any other person while at
camp, and failure to do so is a violation of camp rules that will result in disciplinary action, up to and
including removal from camp. Attach separate page if necessary.
I hereby release Champions Swim and Travel Experience, officers, directors, representatives, members,
agents, employees, or coaches from any and all liability in any way resulting or arising from the
administering of the above medications.
____________________________________
________________________________
Parent/Guardian Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal