Required Medical Forms University Of Texas At Austin (Page 2 of 4) in pdf

The University of Texas at Austin

Department of Intercollegiate Athletics

REQUIRED ME DICAL FORMS

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CONSENT TO TREAT A MINOR

I, the undersigned, as the parent or legal guardian of _____________________________ (a minor) hereby authorize such diagnostic,

medical and/or surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for the

treatment of any illness or injury of the minor. The attending provider, appropriate staff, and The University of Texas at Austin and is

officers, regents, and employees shall not be responsible in any way for any consequences from said diagnostic, medical, and/or

surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to

such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and

to the best of their ability.

SIGNATURE OF PARENT/LEGAL GUARDIAN

DATE

PRINT NAME

PERMISSION TO DISPENSE

Will the youth need to take any prescription medication at camp? ☐ Yes ☐ No

If YES, please list the specific prescription, and daily dosage.

Medication

Reason(s) for Medication

Daily Dosage/Time(s) Taken

Over The Counter Medications:

Ibuprofen (Advil) ☐ Yes ☐ No; Acetaminophen (Tylenol) ☐ Yes ☐ No;

Antacids / Anti-Nausea: Maalox ☐ Yes ☐ No; Throat / Cough Lozenges: ☐ Yes ☐ No;

Allergies: Benadryl ☐ Yes ☐ No

Other Non-prescription Medicine which may be administered: ________________________________________________

I ______________________________________, the parent/guardian of _______________________________________ give

permission to the staff of the UT Sponsored Sports Camp to administer the prescription medications listed above.

The UT Sponsored Sports Camp’s designated personnel 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 responsibility of the parent/guardian 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.

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.

I hereby release The University of Texas at Austin, its Board of Regents, officers, employees, and representatives from any and all

liability in any way resulting or arising from the administering of the above medication.

SIGNATURE OF PARENT/LEGAL GUARDIAN

DATE

Revision Date: 12/7/2015

Required Medical Forms University Of Texas At Austin Page 2