YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE SPECIAL REQUIREMENTS FORM AND AGREE TO ALL TERMS AND CONDITIONS CONTAINED HEREIN. I HEREBY AUTHORIZE THE STAFF OF THE BOYS AND GIRLS CLUB OF NIAGARA TO ADMINISTER THE MEDICATION AS INDICATED ON THIS FORM. I UNDERSTAND THAT ALL MEDICATIONS MUST BE CONTAINED IN THE ORIGINAL PRESCRIPTION BOTTLE AND CAN ONLY BE CHANGED BY THE PARTICIPANT'S PHYSICIAN OR PHARMACY. I AGREE TO NOT HOLD RESPONSIBLE ANY MEMBER OF THE CLUB STAFF FOR ANY ADVERSE EFFECTS THE MEDICATION MAY HAVE ON THE PARTICIPANT. IF THE ABOVE HAS NOT BEEN COMPLETED, I ACKNOWELDGE THAT THE PARTICIPANT IS NOT TAKING ANY MEDICATION FOR THE DURATION OF THEIR TIME WITH THE BOYS AND GIRLS CLUB OF NIAGARA.