MEDICATION RELEASE FORM 2021

First Congregational Church in Winchester

21 Church Street Winchester MA 01890

(781)729-9180
MEDICATION RELEASE FORM
I give my child name* permission to have in his/her/their possession any medication(s) he/she/they may require during overnight or off-site events sponsored by the First Congregational Church in Winchester.
I have reviewed the proper dosage and use of any medication(s) with my child and give him/her/them my permission to self administer his/her/their medication(s) as needed.

I understand that the chaperones for this event will not be responsible for holding medications or administering medications.
(signature of parent/guardian)*

Clear
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Emergency Phone Number*

Area CodePhone Number
Date*

MonthDayYear
Date
I will be bringing my own medication(s) with me. I know how and when to take my medicine(s). I will be responsible for the safe use and storage of my medication(s) during this trip. I will not share any medications with other people during the course of this trip. This includes over the counter medications, such as aspirin, cough drops or cold medicine. (The chaperones will have a basic first aid kit available for participants).
(signature of FCCW youth)*

Clear
FCCW Youth Name*

First NameLast Name
Date*

MonthDayYear
Date
List all medications, including over the counter. Include the medication name, dose, amount taken, schedule and any additional necessary information.*
Should be Empty: