2024 Summer Tri-Wing MDH-4758-C Asthma Action Plan

MDH-4758-C: Asthma Action Plan and Medication Administration Authorization Form
ONLY cadets that has an inhaler or other asthma-related medications must submit a completed Asthma Action Plan and Medication Administration Authorization Form. Wet signatures are required on this form.
1. Download a form at the link below:
  1. https://test-health.maryland.gov/phpa/OEHFP/CHS/Documents/Youth%20Camps/MedicationAdministrationAuthorizationFormAsthmaAction.pdf
2. Complete the form and obtain required WET signatures which includes both Physician and parent/guardian signatures.
3. An electronic copy/scan/photo must be submitted using this online form.
4. A completed hardcopy of the the signed for with original WET signatures must be brought to in-processing.
Name*

First NameLast Name
CAP ID*
Date of Birth*

MonthDayYear
Date
Date Asthma Action Form Signed*

MonthDayYear
Date
Please upload a photo or scan of the COMPLETED/SIGNED Asthma Action Plan. Make sure the document can be clearly read and is signed by both the parent and physician. Medication cannot be dispensed if this form is not completed in its entirety and signed.*

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MDH-4758-C: Asthma Action Plan and Medication Administration Authorization Form