Medical History Supplemental (Page 2 of 2) in pdf

MEDICAL HISTORY SUPPLEMENTAL

6. PRESCRIPTION OR NON-PRESCRIPTION MEDICATION (Use additional documents if more than three medications are provided)

6a. Name of Medication

6b. Strength

6c. Total Quantity Required

6d. Total Quantity Required

6e. Storage (Use Block 7, if necessary)

6f. Frequency and Dosage (check one)

As needed, as labeled

On schedule, as labeled

Other: See Block 6l and/or Block 7

Refrigerate

Child-Proof Cap

Other:

6g. Prescribing Provider Name

6h. Prescribing Provider Phone Number

6i. Prescribing Provider Phone Number (alternate)

6j. Reason for medication (Describe in detail if necessary)

6k. Relevant side effects to be observed if any: (Such as reactions to food, dehydration, sun sensitivity, hives, other medication restrictions, decreased balance/motor

skills, hyperactivity, concentration, drowsiness, lethargy, etc.)

6l. List any other important information about this medication since access to medical information or facilities could be delayed due to training activates or location.

6m. Expected effects if medication is not taken as directed

7. REMARKS (please include comments as required by Blocks 4, 5 and/or 6. Also provide any other medical history that you or your physician deems important)

Parent/Guardian

8. STATEMENT OF UNDERSTANDING AND CONSENT

Initial Below

8a. During the NSCC/NLCC training evolution, NSCC medical personnel on duty and/or assigned NSCC staff members have my permission to

administer the medication listed in Block 4, Block 5 and/or Block 6. I understand that all medications provided to the NSCC training contingent staff,

must be in the original medication bottle containing all of the information required by Block 4, 5, and/or 6.

8b. I give consent to the NSCC staff to contact the medical provider as needed for clarification with regard to medications listed and the conditions for

which the medication is prescribed. The medical provider has been notified that the NSCC is authorized to obtain medical/prescription information if

necessary.

8c. I understand that all medications will be collected at the beginning of training and administered to the Cadet based on dosing instructions on the

medication bottle/package. In no instance will Cadets be allowed to self-medicate with any medication whether it is over the counter or prescription. I

understand I must provide the required amount of medication needed for the entire duration of the training evolution.

8d. I understand that the Commanding Officer of the Training Contingent (COTC), and/or National Headquarters (NHQ) retains the authority to not

accept and/or terminate Cadet’s training at any time due to medical/other reasons. If terminated, parent agrees to immediately pick up their son/daughter

upon notification by the COTC and/or training staff.

9. AUTHORIZATION AND RELEASE

I certify that, to the best of my knowledge, the information provided is true and accurate and I have disclosed all pertinent medical history. Furthermore,

I authorize the Naval Sea Cadet Corps, its agents, officials, and training staff members, to dispense medication listed on this authorization and I “Hold

Harmless” the Naval Sea Cadet Corps from any and all liability, actions, or causes of action for damages or injury that may arise, directly or indirectly,

from my child’s use of medication while participating in Naval Sea Cadet Corps activities. I understand that training staff members may not be medical

professionals and that medication will be dispensed according to the manufacturer’s instructions and/or the instructions I provided on this authorization.

9a. Name of Parent/Guardian (Type or Print)

9b. Signature

9c. Date (DD MMM YY)

10. ENDORSEMENTS

I have reviewed the medical record of this cadet and certify that the medications listed on this form are true and correct as prescribed and that this cadet is

physically able to attend the listed training evolution.

10a. Name of Medical Provider (Type or Print)

10b. Signature

10c. Date (DD MMM YY)

I certify that I have reviewed the above information and the Cadet listed on this form is physically able to attend the listed training evolution.

10d. Name of Commanding Officer (Type or Print)

10e. Signature

10f. Date (DD MMM YY)

PREVIOUS EDITIONS ARE OBSOLETE

NSCADM 001 (Rev 08/14), Page 8

Formerly NSCTNG 025