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R A L E I G H P A R K S, R E C R E A T I O N A N D C U L T U R A L R E S O U R C E S

22

2016-2017 Registration

(cont.)

Medication Permission Form

Permission Form for Assisted Administration of Medication

Parks, Recreation and Cultural Resources (PRCR) employees only administer medication to participants if:

1. The City of Raleigh permission

form for assisted administration of

medication is completed and in the

possession of the PRCR staff.

2. A PRCR employee will not give

medications unless it is in an

original container with appropriate

medicine contained within, with a

visible label including the name of

medication, the date of expiration,

clear dosage amount and directions

with the participant’s name CLEARLY

INDICATED on the bottle/box.

The Parent/Guardian is responsible for the following with ALL medication:

1. Complete and sign the portion of

the form below and return to the

program staff.

2. Provide medication in an original

container with visible label including

the name of medication, the date

of expiration, clear dosage amount

and administration directions with

the participant’s name CLEARLY

INDICATED. Note: Inhalers outside

the original package must be

accompanied by a copy of the

original package label noting the

above information.

3. Provide new, labeled containers if/

when medication changes are made.

4. Parents/guardians must transport

medication to program site and give

directly to program staff.

5. Parent/guardian must pick up

medication at the end of each week/

program from program staff. Medica-

tions not picked up at the end of 14

business days following the last day

of participation in the program will

be disposed of by program staff.

6. PRCR program employees will

dispose of empty containers (unless

otherwise instructed).

7. For prescription medications: The

pharmacy label will serve as the

physician’s authorization for the

medication to be administered. Have

the pharmacist label two containers:

one for home use and one for use in

the program, if the participant is to

receive medication at both sites.

8. If the medication is an EPI pen or

inhaler, it is recommended (not re-

quired) that the pharmacist label two

containers to keep at the program

site. The parent/guardian should

check to ensure the medication does

not exceed the printed expiration

date. Program staff will not accept

expired medication.

9. For non-prescription medications:

The medication must be adminis-

tered according to the dosage and

administration instructions on the

original container.

**A physician’s signature will

be required as authorization IF

medication is requested to be given

in an alternate dosage, etc.

10.Parents/guardians should notify

program staff in writing as soon as

possible if there are any changes to

instructions for the administration

of medication once these forms has

been submitted. A new form may be

required.

PERMISSION FORM FOR ASSISTED ADMINISTRATION OF MEDICATION

By completing the information below, the Parks, Recreation and Cultural Resources staff is authorized to administer

any medication(s) that are provided as indicated above.

Participant’s Name___________________________________________________________________________________

1) Name of medication: _ ______________________________________________________

a

Prescription

a

Non-prescription

Dosage: _ _________________________________________ Times: _ ___________________________________________________

Reason for Medication: _ _______________________________________________________________________________________

Side effects:_ __________________________________________________________________________________________

2) Name of medication: _ ______________________________________________________

a

Prescription

a

Non-prescription

Dosage: _ _________________________________________ Times: _ ___________________________________________________

Reason for Medication: _ _______________________________________________________________________________________

Side effects:_ __________________________________________________________________________________________

Parent/Guardian Name ________________________________________________________________________________________

Parent/Guardian Signature _____________________________________________________________ Date________________

**ONLY under special circumstances for Non-Prescription medications (see #9 above).

Physician Name _ _______________________________________________________________________________________________

Physician Signature _ ____________________________________________________________________ Date_ _______________