Medication Authorization

Medication Authorization

2022-2023 CHS Winter Guard
Please complete this form so that, in the event your student needs medicine (over-the-counter and/or prescription) during practice and/or a competition, we have your permission to adminster it.

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, melatonin etc
- Some basic over-the-counter medicines are supplied by the Boosters and available from the coach on an as needed basis (Tylenol, Motrin, antiacids, etc.) while team events are undeway.
- All medication brought from home, including over-the-counter meds, should be given to the coach or chaperone upon arrival. For the safety of all of our students and staff, we do not allow medication to remain with students (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 Full Name*
Birth Date*

MonthDayYear
Over-the-Counter Medications
Please select YES or NO to the following over-the-counter medications that your child may be given, if the need arises. Medications will be administered as directed on the packaging, if needed. It is up to the coach or chaperone to decide whether or not to dispense non-prescription. Parents will be contacted if there is any question, whatsoever.

	Yes	No
Acetaminophen (Tylenol) for pain relief, swelling
Ibuprofen (Advil, Motrin) for pain relief, swelling
Phenylephrine decongestant (Sudafed PE) for congestion
Cough Syrup (Robitussin) for cough
Diphenhydramine antihistamine
(Benadryl) for swelling, hives, allergic reaction
Cetirizine (Zyrtec) or loratadine (Claritin) for environmental allergies
Throat lozenges or spray for sore throat
Bismuth subsalicylate (Pepto-Bismol) for diarrhea or upset stomach
Loperamide (Immodium A-D) for diarrhea
Laxatives (Milk of Magnesia, Ex-Lax) for constipation or upset stomach
Calamine lotion for bug bites or poison ivy
Antibiotic cream/ointment for minor wound care
Hydrocortisone 1% cream for mild skin irritations, poison ivy, or insect bites
Aloe for sunburn
Anti-fungal cream (Micatin) for athlete’s foot
Eye drops for minor eye irritation

PLEASE INCLUDE ACTION PLANS FOR ANY SERIOUS MEDICAL ISSUES (e.g. EPI Pens, Seizures, Diabetes, Inhalers, etc.)
Parent/Guardian Signature*

Clear
Parent/Guardian Name*
Date*

MonthDayYear
Best Phone #*
Email Address
We will send you a confirmation email of your responses.
Should be Empty:

Medication Authorization

Over-the-Counter Medications

Prescription or Routine Medications