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Formc (University of Southern Mississippi)

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FORM: USM Consent to Med TX, Prescript, OTC Meds
Form Date: 11.19.2014
THE UNIVERSITY OF SOUTHERN MISSISSIPPI - YOUTH PROGRAM/CAMP
WAIVER AND CONSENT FOR MEDICAL TREATMENT, SELF-ADMINISTRATION OF PRESCRIPTION
MEDICATION, AND OVER-THE-COUNTER MEDICATION
______________________________________________________________________________________________
PROGRAM/CAMP INFORMATION
Program/Camp Name: ____________________________________________________________________________________
Date(s): ________________________________________ Time(s): _____________________________________________
Location: _______________________________________________________________________________________________
The information requested on this form is intended to help inform program staff of any pre-existing medical conditions of participant.
This information will be kept in strict confidence and will only be shared with your permission. The University requests the
information below so that, in case of emergency, it will have accurate information so that it can provide and/or seek appropriate
treatment for Participant. If Participant has a pre-existing medical condition, participation in any strenuous activities or recreational
time may not be recommended. The requested medical information disclosed will not be used by the University personnel or
employees to determine Participant’s ability to participate safely in activities. You, as participant, parent or guardian understand that
the final determination about whether to participate is the responsibility of you and your physician.
You are accountable for providing an accurate medical history. If Participant has any medical issue that is not requested below, but
which you think is important, please include that information. It is recommended that you consult with a physician prior to
participating in this Program. If you are uncertain about any preexisting medical conditions, it is your responsibility to consult with
your own physician prior to participating in this Program. You understand that, if Participant chooses to participate in activities,
he/she does so voluntarily and of his/her own accord and the final decision regarding participation is solely the responsibility of
yourself, Participant, and your physician.
By signing your name under Medical Information, you acknowledge your agreement to the terms and conditions contained therein and
you certify that all responses made on this form are complete, true, and accurate.
You understand that the University [does or does not] offer an excess medical insurance policy for participants to cover medical
expenses for injuries/accidents that occur in the course of the program’s activities. Medical expenses that are declined for
payment through the participant’s personal insurance and/or through the excess policy (if applicable) become the responsibility of
the participant’s parent/guardian.
PART 1. GENERAL INFORMATION
Participant Name (hereafter “Participant”) _________________________________________________________________________
Parent/Legal Guardian Name (if applicable) ________________________________________________________________________
Street Address ________________________________ City ______________________ State _________________ Zip _________
Home or Cell Phone _______________________________________Work Phone_________________________________________
Date of Birth _______/_______ /_______ Gender: M _______ F _______
Please list two emergency contacts:
__________________________ ___________________ __________________ _____________ _______________
Emergency Contact #1 Name Home Phone # Work Phone # Cell Phone # Relation
__________________________ ___________________ __________________ _____________ _______________
Emergency Contact #2 Name Home Phone # Work Phone # Cell Phone # Relation
PART 2. MEDICAL INFORMATION
FORM: USM Consent to Med TX, Prescript, OTC Meds
Form Date: 11.19.2014
It is recommended that Participant consult with your physician prior to participating in this Program. If you are uncertain about any
preexisting medical conditions, it is your responsibility to consult with your own physician prior to participating in this Program.
Please answer all of the questions. If you answer yes to any of the following questions, please explain as indicated. Use back and/or
additional paper if needed.
Physician’s Name __________________________________ Phone Number ____________________________
Date of most recent tetanus toxoid immunization _____________________________________________________
Do you have health/accident insurance? (circle one): YES NO
If yes, please indicate policy number, name and address of insurance company.
Company Name / Address ___________________________________ Policy # ____________________
For the following, circle appropriate response and explain as appropriate:
Does participant have any limiting medical conditions that you or your doctor feel would limit camp participation? YES NO
If yes, identify and explain:
Is participant currently taking medication that may interfere with ability to safely participate in Program? YES NO
If yes, please indicate the medication and the condition being treated:
Does participant have a history of allergies or reactions to medications, insect stings, or plants? YES NO
If yes, please explain:
Does participant have a history of, or currently suffer from, medical condition(s) with which we need to be aware? YES NO
If yes, please explain:
Parent/Guardian Name _______________________________ Parent/Guardian Signature ______________________
Participant Signature
(if 18 or older)________________________ Date _________________________________________
PART 3: WAIVER AND CONSENT FOR MEDICAL TREATMENT
I, the undersigned parent/guardian, do hereby grant permission for my son/daughter/ward to receive necessary medical treatment, and
give permission to The University of Southern Mississippi, through its representatives, to seek treatment for said son/daughter/ward,
in the event of an injury or illness while at the University during the period of the program.
Furthermore, I accept responsibility for full payment of such medical treatment not covered by insurance. I hereby hold the University
and its representatives harmless in the exercise of this authority.
Parent/Guardian Name _______________________________ Parent/Guardian Signature ______________________
Participant Signature
(if 18 or older)______________________ Date _________________________________________
FORM: USM Consent to Med TX, Prescript, OTC Meds
Form Date: 11.19.2014
PART 4: AUTHORIZATION FOR OVER-THE-COUNTER MEDICATION
Over-the-Counter (OTC) Medication may at times need to be administered, if approval is indicated by the participant’s parent or
guardian. Please complete the following section to save time if your child needs any of these OTC medications during his/her stay.
Note: Unless we have parental authorization, we cannot administer ANY medications.
I hereby authorize that the following medications may be given to Participant if the need arises. You may dispense only those
checked.
Ointments for minor wound care, first aid as directed. (Antiseptic, anti-itch, anti-sting, antibiotic, sunburn)
Tylenol/Acetaminophen as directed.
Ibuprofen as directed.
Throat lozenges and or spray as directed for sore throat.
Micatin or anti-fungus treatment as directed for athlete’s foot.
Kaopectate or Imodium for diarrhea as directed.
Milk of Magnesia, Pepto Bismol or Mylanta for upset stomach or nausea as directed.
Rolaids or Tums for acid reflux, heartburn or indigestion as directed.
Benadryl for swelling, hives, allergic reaction, as directed.
Actifed or Sudafed as directed for nasal congestion or allergy relief per instructions.
Visine or other eye drops for minor eye irritation.
Medicated lip ointment for dry, chapped lips, lip blisters or canker sores as directed.
Swimmer’s ear drops as directed.
Hydrocortisone ointment as directed for mild skin irritations, poison ivy, and insect bites.
Medicated powder for skin irritation as directed.
Robitussin or other cough syrup as directed.
Calamine lotion for bug bites and poison ivy.
Sunscreen
Bug repellent
Other (list any other approved over-the-counter drugs) ____________________________________________________
Program staff reserves the right to use generic equivalents when available for the name brand over-the-counter medications listed
above.
I understand that such administration will not be done under the supervision of medical personnel. I also agree that any first aid
treatment may be given as needed.
Any condition which is associated with fever, significant inflammation, and/or does not respond to the above outlined treatment will
be followed-up by a consultation with the participant’s parents. Parent/guardian will be contacted if any conditions develop requiring
treatment with any of the above over-the-counter medications that are not checked.
I understand that these over-the-counter medications are not necessarily kept on hand and available to be administered immediately.
I authorize the administration of over-the-counter medications to my child as indicated above. I shall indemnify and hold harmless the
University and any of its representatives, employees or agents against any claims that may arise relating to my child being
administered the above indicated over-the-counter medications. I/We have legal authority to consent to medical treatment for the
participant named above, including the administration of medication at the above referenced program.
Parent/Guardian Name __________________________ Parent/Guardian Signature ____________________________
Date ____________________________________________
FORM: USM Consent to Med TX, Prescript, OTC Meds
Form Date: 11.19.2014
PART 5: AUTHORIZATION FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION
This form must be completed fully in order for the participant identified above to self-administer prescription medication during the
program identified above. A separate form must be completed for each medication to be administered. Self-administration of
medication requires the written authorization (below) of Participant’s parent or legal guardian.
No, my child does not need to take any prescription medication during the Program.
(Please stop and sign the form at the bottom of the page)
Yes, my child will need to take a prescription medication during the Program.
(Please fill out the rest of this form and sign at the bottom of the page)
All prescription medications, including medications for conditions such as food, drug, or insect allergies; diabetes; asthma; or epilepsy
may be brought to the Program under the condition that Participant can self-manage care and delivery of medication. Prescription
medication must be in its original container labeled with the minor’s name, medication name, dosage, and time/frequency of
administration.
AUTHORIZATION FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION
Medication name:_________________________________________ Dose:_________________________________________
Condition(s) for which medication is being administered: _________________________________________________________
Specific directions (e.g., on empty stomach, with water): ________________________________________________________
Time/frequency of administration: __________________________________________________________________________
If PRN, frequency: ______________________________________________________________________________________
If PRN, for what symptom(s): _____________________________________________________________________________
Relevant side effect(s): ___________________________________________________________________________________
Medication shall be administered from (date) _____________________________ to __________________________________
Special storage requirements:______________________________________________________________________________
Is Participant capable of self-managed care: YES NO
Prescribing health professional’s name: _________________________________________________________________________
I hereby authorize and recommend Participant to self-administer the above-described medication. I hereby affirm that
Participant has been instructed in the proper self-administration of the above-described medication.
Parent/Guardian Name ____________________________ Parent/Guardian Signature ________________________
Date ____________________________________________
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Completed 26 July 2020

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