Over the Counter and Medication Permission Form

I understand it is my responsibility to give medications (including inhalers) directly to the program staff in the originial prescription containers in a gallon size zip lock bag clearly labeled with the participants name. 

In all cases the recommended dosage of any medication will not be exceeded. If after administering medication there is an adverse reaction, I give my permission to Golden Heart Ranch to secure from any licensed hospital physicial and/or medical personnel any treatment deemed necessary for immediate care. I agree to be responsible for payment of any and all medical services rendered. 

I recognize and acknowledge that there are certain risks of physical injury in connection with the administering of medications to my child. In consideration of Golden Heart Ranch's administering medication to my child, I do hereby fully release or discharge Golden Heart Ranch, and its officers, agents, volunteers, and employees from any and all claims from injuries, damages and losses I or my child may have, arising out of, connected with, incidental to, or in any way associated with the administering of medication. I further agree to indemnify, hold harmless and defend Golden Heart Ranch, and it's officers, agents, volunteers and employees from any and all claims resulting from injuries, damages and losses sustained by me or my child and arising out of, connected with incidental to or in any way associate with the administering of medication. 

I hereby acnkowledge that the information provided for the dispensing of medication for my child, guardian, ward, or other family member is accurate. I also understand that it is my responsibility to inform the agency if any changes in the dispensing of medication changes. I will do so by completing another Medication Information Form. 

Over-the-counter (OTC) medications are drugs that do not require a prescription and are purchased "over-the'-counter". This form is required before OTC medications can be administered at Golden Heart Ranch. Should the need arise, parent(s) will be contacted for any medication applied/given. 

I give the Ranch staff permission to administer the over-the-counter medications indicated above, should the need arise, while my child is participating in  Golden Heart Ranch programs.