US Youth Soccer ODP Medication Form

Instructions
Prescription or over-the-counter (OTC) 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 the medications will be secured by program staff and made available to participant for self-administration as authorized in writing by the participant’s parent/guardian. It is the participant’s responsibility to come to get their medications, but program staff will make every effort to remind them as needed. If the participant is unsure of the medication to take or the correct dosage, program staff will contact the parent or guardian for clarification.

Medication must be in its original container and all labels must be intact with instructions clearly legible. Prescription medications must be labeled by the pharmacist or prescriber, with the name, address and phone number for pharmacist or prescriber. It is advised that containers hold only the amount required for the time the participant will be attending the Program. If a tablet should be cut in half, this should be done before the submitting medication to the Program. Please send medicine cups for liquid medications.

All medications for a single participant should be stored in a plastic bag labeled with the participant’s name and date of birth. All medications and medication bags will be returned to the participant’s parent/guardian when the program is over.

This form must be completed fully in order for participants to self-administer required prescription or OTC medication. A new Medication Management form is required for each program attended by the participant, each medication, and each time the is a change in dosage or time of administration of a medication.

Note: Unless we have prior parental authorization, we cannot provide ANY OTC medications.
Youth Program Medican Management Form
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Medication Information - fill any irrelevant fields below as N/A
Special Storage Requirments
Authorization

By signing at the bottom of this document I authorize the following:

 

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* Indicates Response Required