AUTHORIZATION FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION Sample Clauses

AUTHORIZATION FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION. Medication Name: Dose: Condition for which medication is being administered: Specific Directions (e.g., on empty stomach,/with water, etc.) Time/frequency of administration: If PRN, frequency: If PRN, for what symptoms: Relevant side effects: Medication shall be administered from / / to / / Special Storage Requirements: Is the youth Program Participant capable of self-managed care? Prescriber’s Name/Title: Prescriber’s place of employment: Telephone: Fax: I hereby affirm that this individual has been instructed in the proper self-administration of the prescribed medications(s) Prescriber’s Signature: Date: _ X. XXXXXX/GUARDIAN AUTHORIZATION, WAIVER AND CONSENT FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION I authorize and recommend self-medication by my child for the above medication. I also affirm that he/she has been instructed in the proper self- administration of the prescribed medication by his/her attending physician. I shall indemnify and hold harmless the Institution, its governing board, officers, employees, and representatives against any claims that may arise relating to my child’s self-administration of prescribed medication(s). I/We have legal authority to consent to medical treatment for the camper named above, including the administration of medication at the above referenced youth program. Parent/Guardian Signature: Date: Home phone # Cell Phone # Work Phone #