22-23 Medication Authorization

CHS Marching Band Medication Authorization (2022-2023)

(please complete this entire form)
Medication can only be administered with written permission from legal parent/guardian. Medications include: prescriptions, over-the-counter medications, homeopathic remedies, and supplements (e.g., vitamins, Tylenol, Benadryl, inhalers, etc.)

All medication, including over-the-counter meds, should be given to the person overseeing first aid (coach, nurse, band director or first-aid volunteer) upon arrival at camp, practice or games.

For the safety of all of our students and staff, we do not allow students to keep possession of any medication during school events (except for inhalers and EPI pens

Prescription medications MUST be in the original bottle/packaging that identifies the prescribing physician, name of medication, dosage, and frequency of medication.

Students should know what their medication is, be able to recognize it, know the dosage, and when they should take it. (This is always good practice!)
Student's Name*

First NameLast Name
Birth Date

MonthDayYear
Please select YES or NO for each of the following over-the-counter medications that you will allow your student to be given during camp, practices or games, upon their request. Medications will be administered as directed on the packaging at the discretion of the band director, nurse, first aid volunteer and/or chaperone.
Acetaminophen (Tylenol) for pain relief, swelling*

YesNo
Ibuprofen (Advil, Motrin) or Naproxen (Aleve) for pain relief, swelling*

YesNo
Phenylephrine decongestant (Sudafed PE) for congestion*

YesNo
Cough Syrup (Robitussin) for cough*

YesNo
Diphenhydramine antihistamine (Benadryl) for swelling, hives, allergic reaction*

YesNo
Cetirizine (Zyrtec) or loratadine (Claritin) for environmental allergies*

YesNo
Throat lozenges or spray for sore throat*

YesNo
Bismuth subsalicylate (Pepto-Bismol) for diarrhea or upset stomach*

YesNo
Loperamide (Immodium A-D) for diarrhea*

YesNo
Laxatives (Milk of Magnesia, Ex-Lax) for constipation or upset stomach*

YesNo
Calamine lotion for bug bites, hives or poison ivy*

YesNo
Antibiotic cream/ointment for minor wound care*

YesNo
Hydrocortisone 1% cream for mild skin irritations, poison ivy, or insect bites*

YesNo
Aloe (for sunburn)*

YesNo
Anti-fungal cream (Micatin) for athlete's foot*

YesNo
Eye drops for minor eye irritation*

YesNo
Prescription or Routine Medications*

NO - (Skip to Final Section below) - student will not take any medications routinely during camp, practices and/or games.YES, student will take routine medication(s) as listed below:
Complete this section only if routine meds will be given or might be needed during camp, practice or games.
Name of Medication - #1
Dose
Reason for taking
Time to be given
Storage constraints
How it is given

OralInjectionInhaler
MUST be kept on the student's person or in close proximity. i.e. EPI pen, inhaler, etc

Yes
Describe action plan, in case medication must be used
Name of Medication - #2
Dose
Reason for taking
Time to be given
Storage constraints
How it is given

OralInjectionInhaler
MUST be kept on the student's person or in close proximity. i.e. EPI pen, inhaler, etc

Yes
Describe action plan, in case medication must be used
Name of Medication - #3
Dose
Reason for taking
Time to be given
Storage constraints: (i.e. refrigeration or exposure to light)
How it is given

OralInjectionInhaler
MUST be kept on the student's person or in close proximity. i.e. EPI pen, inhaler, etc

Yes
Describe action plan, in case medication must be used
PLEASE INCLUDE ACTION PLANS FOR ANY SERIOUS MEDICAL ISSUES (e.g. EpiPens, Seizures, Diabetes, Inhalers, etc).
Final Section
Parent/Guardian Name*
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Best Phone*
Should be Empty:

CHS Marching Band Medication Authorization (2022-2023)

Complete this section only if routine meds will be given or might be needed during camp, practice or games.

Final Section