Medication Distribution Release

MEDICATION DISTRIBUTION RELEASE

Youth Resources requires a medication distribution release for every student participant who will need to take prescription medication while at TEENPOWER. A parent or guardian should complete the medication distribution release below and provide their e-signature.

If you have any additional information regarding your student’s prescription medication, or you run into any issues completing the form, please call YR at 812-421-0030. Thank you!

Medication Policies

• Prescription medication MUST be held and administered by Youth Resources while your child is at TEENPOWER.
• All non-emergency, prescription medication must be turned in to Youth Resources at TEENPOWER check-in.
• Emergency prescription medication – such as rescue inhalers and insulin – may remain on the student.
• Please fill out the form below for both emergency and non-emergency prescription medication.
• Over the counter medications like Advil or vitamins do not need to be turned in at check-in.
• TEENPOWER staff will have over the counter medication that can be provided to your student with parental consent via the health & liability form.

How to Bring Your Student’s Medication to TEENPOWER

• Prescription medications must be brought to TEENPOWER in the original pharmacy bottle.
• The label on the pharmacy bottle should meet the requirements for the physician’s signature.
• Prescription medication requires written permission (below) from parent/guardian stating the amount of medication, hours for administration, and period of time that the medication is to be continued.
• Medications must be picked up at TEENPOWER check-out. Any medications left behind will be destroyed.

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- Step 1 of 3

I am submitting this information for my child's participation in:High School TEENPOWERMiddle School TEENPOWER

STUDENT INFORMATION

First Name *

Middle Name

Last Name *

Date of Birth *

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Age *

Gender *GenderMaleFemaleOther genderPrefer not to answer

If other, please describe preferred gender:

PRESCRIPTION MEDICATION 1

Medication 1: Prescription Name

Medication 1: How much medication should be distributed at each instance? (Milligrams preferred)

Medication 1: How often (times per day) should this medication be distributed?

• 1x
• 2x
• 3x
• As needed
• Emergency only

Medication 1: When should this medication be distributed?

• Breakfast/morning
• Lunch/afternoon
• Dinner/evening
• Bedtime
• Other or specific time

If medication is taken more than once per day, please check ALL time periods that apply.

Medication 1: If other or specific time, when should this medication be distributed?

Medication 1: Refrigeration Required

• Yes
• No

Medication 1: Notes or Other Instructions

Do you have other medication to report?

• Yes
• No

PRESCRIPTION MEDICATION 2

Medication 2: Prescription Name

Medication 2: How much medication should be distributed at each instance? (Milligrams preferred)

Medication 2: How often (times per day) should this medication be distributed?

• 1x
• 2x
• 3x
• As needed
• Emergency only

Medication 2: When should this medication be distributed?

• Breakfast/morning
• Lunch/afternoon
• Dinner/evening
• Bedtime
• Other or specific time

If medication is taken more than once per day, please check ALL time periods that apply.

Medication 2: If other or specific time, when should this medication be distributed?

Medication 2: Refrigeration Required

• Yes
• No

Medication 2: Notes or Other Instructions

Medication 2: Do you have other medication to report?

• Yes
• No

PRESCRIPTION MEDICATION 3

Medication 3: Prescription Name

Medication 3: How much medication should be distributed at each instance? (Milligrams preferred)

Medication 3: How often (times per day) should this medication be distributed?

• 1x
• 2x
• 3x
• As needed
• Emergency only

Medication 3: When should this medication be distributed?

• Breakfast/morning
• Lunch/afternoon
• Dinner/evening
• Bedtime
• Other or specific time

If medication is taken more than once per day, please check ALL time periods that apply.

Medication 3: If other or specific time, when should this medication be distributed?

Medication 3: Refrigeration Required

• Yes
• No

Medication 3: Notes or Other Instructions

Medication 3: Do you have other medication to report?

• Yes
• No

PRESCRIPTION MEDICATION 4

Medication 4: Prescription Name

Medication 4: How much medication should be distributed at each instance? (Milligrams preferred)

Medication 4: How often (times per day) should this medication be distributed?

• 1x
• 2x
• 3x
• As needed
• Emergency only

Medication 4: When should this medication be distributed?

• Breakfast/morning
• Lunch/afternoon
• Dinner/evening
• Bedtime
• Other or specific time

If medication is taken more than once per day, please check ALL time periods that apply.

Medication 4: If other or specific time, when should this medication be distributed?

Medication 4: Refrigeration Required

• Yes
• No

Medication 4: Notes or Other Instructions

Do you have other medication to report?

• Yes
• No

PRESCRIPTION MEDICATION 5

Medication 5: Prescription Name

Medication 5: How much medication should be distributed at each instance? (Milligrams preferred)

Medication 5: How often (times per day) should this medication be distributed?

• 1x
• 2x
• 3x
• As needed
• Emergency only

Medication 5: When should this medication be distributed?

• Breakfast/morning
• Lunch/afternoon
• Dinner/evening
• Bedtime
• Other or specific time

If medication is taken more than once per day, please check ALL time periods that apply.

Medication 5: If other or specific time, when should this medication be distributed?

Medication 5: Refrigeration Required

• Yes
• No

Medication 5: Notes or Other Instructions

Next

PRESCRIPTION MEDICATION ADMINISTRATION AUTHORIZATION

1. I herewith acknowledge that I am primarily responsible for administering medication to my child. However, in my absence, I hereby authorize Youth Resources of Southwestern Indiana and its TEENPOWER Adult Staff employees to administer to my child the medications listed above.

2. I further acknowledge and agree that when the above medication is administered, I waive any claims I might have against Youth Resources of Southwestern Indiana and its staff arising out of the administration of said medication.

3. In addition, I agree to hold harmless and indemnify Youth Resources of Southwestern Indiana and its staff, either jointly or severally, from and against any and all claims, damages, causes of action or injuries incurred or resulting from the administration of said medication.

Parent/Guardian Signature *

Please type your name above as your e-signature.

Parent/Guardian Cell Phone *

Parent/Guardian Work Phone

Next

*EMERGENCY-USE MEDICATION ONLY* SELF-CARRY AND SELF-ADMINISTER AUTHORIZATION

1. I acknowledge that my student can carry and self-administer EMERGENCY medication such as a rescue inhaler or insulin, and I have listed details of said emergency medication above.

2. I further acknowledge that my student has been instructed on how to self-administer the medication and is capable of doing so, and that the nature of the student's disease or condition may require emergency administration of this medication.

3. I waive any claims I might have against Youth Resources of Southwestern Indiana and its staff arising out of the self-administration of said medication.

4. In addition, I agree to hold harmless and indemnify Youth Resources of Southwestern Indiana and its staff, either jointly or severally, from and against any and all claims, damages, causes of action or injuries incurred or resulting from the self-administration of said medication.

Parent/Guardian Signature

Please type your name above as your e-signature.

Submit