Medication Release Request Form printable pdf download

Medication Release / Request Form

YMCA of Boulder Valley School Age Child Care/Camp

According to Colorado State law and the Nurse Practice Act

According to Colorado state law, the following procedures must be followed in order for your child to receive medication from YMCA staff.

Both the Parent / Guardian AND Prescribing Practitioner’s signature must be present on the release / request form.

Medication given by YMCA staff must be physician – prescribed. This includes “over the counter” drugs such as Tylenol, cough syrup,

topical lotions, holistic medications, vitamins, supplements etc.

A medication that is prescribed “as needed” cannot be given unless the prescribing authority provides specific instructions as to the

times and measurable conditions under which the medication should be given. For example, an asthma inhaler prescription might refer

to a peak flow meter measurement, or a fever medication to a degree measurement.

The child’s parent/guardian must provide any items referenced in the prescription, such as a peak flow meter, or other measuring

device.

All medication must be in the original container. Over-the-counter medication containers must be labeled with the child’s name, and, if

not already provided on the container, directions for safe use, expiration date, and a list of ingredients. Directions on the container

must not conflict with the prescribing authority’s directions in order for the medication to be dispensed by program staff.

Prescription medication MUST have the following information on the label.

The child’s first and last name

•

Prescribing practitioners name

•

Pharmacy name and telephone number

•

Date prescription was filled

•

Expiration date of the medication

•

Name of the medication

•

Dosage

•

Route of medication (we only dispense “oral” by mouth or “topical” on skin)

•

How often to give the medication

•

Length of time medication is to be given

•

YMCA staff will not dispense injectable medication unless it is an emergency injection (i.e. epi-pen) that is ordered by a physician to

save a life, such as when a child has an extreme allergy to a bee sting.

Medication will be stored in a locked area inaccessible to children. The child may not carry his / her own medication.

Pills requiring division must be divided before being presented to the program center.

10.

The amount of controlled substances, such as Ritalin, received by the program center must be documented by a staff member and the

parent at the time that medication is received by the center. The number of pills will be documented in the medication log. If/when

any medication is returned to that child’s parents, another documented count will be done at the time of the medication’s return.

11.

Medication along with completed Medication Release / Request Form must be given to a staff member by the parent or guardian.

12.

If the child is taking the medication for en extended amount of time, this form must be reauthorized on at least an annual basis, or

according to expiration date.

13.

If there are ANY changes in the child’s medication, a new form must be completed, and the prescription container must reflect these

changes.

Medication Release / Request Form

To be completed by the Prescribing Practitioner. (Please Print):

Please note: According to Colorado state law, a medication that is prescribed “as needed” cannot be given unless the prescribing authority

provides specific instructions as to the times and measurable conditions under which the medication should be given. For example, an asthma

inhaler prescription might refer to a peak flow meter measurement, or a fever medication to a degree measurement.

Child’s Name ___________________________________________________________________________

Prescribing Practitioner Name _________________________ Address ________________________ State______ Zip _______

Prescribing Practitioner Phone # ______________________

Reason for medication: ___________________________________________________________________

Name of Medication to be given: ___________________________ Dosage:_________________________

Time (s) to be given:______________________________

Route of medication: __________________

Length of time to be given: From (date)_____________________ To (date) _________________________

Side effects or reactions to watch for: ________________________________________________________

Special Instructions: ______________________________________________________________________

_________________________________________________________

____________________

Prescribing Practitioner Signature

Date of authorization

I understand that the above procedures must be followed for YMCA staff to dispense the medication to my child according to the

physician orders listed above.

Parent Signature: _________________________________________

Date ________________

Medication Release Request Form

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