Microsoft word - mass dispensing program consent form

ABERDEEN MASS DISPENSING PROGRAM
HOUSEHOLD ACKNOWLEDGEMENT AND CONSENT FORM
(Print name-in ink) __________________________________________________________
(Print address) ____________________________________, Boynton Beach, Florida, 33472
AS HEAD OF HOUSEHOLD,IUNDERSTAND, ACKNOWLEDGEANDCONSENT TOTHEFOLLOWING STIPULATIONS:
1. CARPOOL RESIDENT MEDICATION PICK-UP AUTHORIZATION FORM
To permit my Representative togo to the clubhousetopick upmedications and instructions for myself, my family and my
visiting guests, who are named on my Client Registration Form.
2. WORSENING MEDICAL CONDITION ADVICE INSTRUCTIONS
To acknowledge that I will assist any household memberlisted on my Client Registration Form who has a Worsening Medical
Condition over the last 48 hours in seeking Medical Attention as soon as possible.
3. PREGNANT & BREAST FEEDING WOMEN INSTRUCTIONS
To acknowledge that if any of the above individuals are listed on my Client Registration Form, I wil instruct them or their
guardian to consult with their personal physicians for additional instructions on how to take the antibiotics- Cipro,
doxycycline or amoxicillin.
4. Samples of the specific strain of pathogen to which we may have been exposed wil have to be tested to determine if it is
susceptible (sensitive) to Amoxicillin (penicillin). It is unlikely that any confirmation will be available during the early stages
of our Antibiotic Dispensing Program. But this information will be most useful should it be necessary to provide treatment
for a total of 60 days.
According to the dispensing guidelines from the Palm Beach County Health Department, all children under 8 years of age will
be dispensed Cipro, according to their weight. Should a child under 8 be allergic to Cipro, then doxycycline wil be dispensed
according to the child’s weight.
Cipro will also be the recommended drug of choice for Pregnant or Breast feeding women. If allergic to Cipro, then
doxycycline will be dispensed due to life threating illnesses, such as Anthrax.
A potential side effect of Cipro is that it may cause joint pain. Everyone is advised to report any joint pain to their physician
while taking Cipro.
A potential long-term side effect of doxycycline is the staining of, but not damage to, tooth enamel. Typically, the staining
only becomes visible after prolonged use of doxycycline (months).
In either case, the advice of the child’s physician should be sought to determine which medication to use for your Child(ren),
and yourself. It is best that this information be obtained prior to an emergency and during a routine doctor’s visit.
Since we are dealing with a possible life threating disease, doxycycline and Cipro are the best available medications to use .
5. To release and discharge the Aberdeen Property Owners Association, Inc., the Aberdeen Golf & Country Club Inc., all
members and participants in the Aberdeen Mass Dispensing Program, including but not limited to the Coordinator of the
Program, the Medical Supervisor, carpool Representatives, the Aberdeen Mass Dispensing Program Team, Volunteer
Members and all volunteers partaking in the administration of said program from any and all liability for any civil damages as
a result of any act or omission of said persons and/or Groups unless such damages result from any act or omission under
circumstances demonstrating a willful, wanton reckless disregard for the consequences, so as to affect the life or health of
another.
6. To Acknowledge that I have been given a printed Anthrax Treatment Information sheet to be shared by my household.
Head of Household Signature_________________________________________________________ Date_________
IMPORTANT- DISTRIBUTE TWO COPIES PER HOUSEHOLD:
YOU MUST SUBMIT ONE SIGNED COPY AT THE DISPENSING SITE AT THE TIME OF A REAL EVENT.
ONE COPY SHOULD BE RETAINED BY HEAD OF HOUSEHOLD FOR YOUR RECORDS.
IF YOU CHOOSE TO OPT OUT OF THIS PROGRAM, THAT IS, REFUSE THE MEDICATION OFFERED, Then:
PLEASE SIGN HERE _____________________________DATE_____ TO RELEASE AND DISCHARGE THE ABERDEEN
PROPERTY ASSOCIATION INC., AND THE ABERDEEN GOLF AND COUNTRY CLUB from any damage or loss that I may
sustain as a result of opting out and the election to opt out is strictly voluntary on my part and not as a result of coercion
or payment of any kind.

Source: http://aberdeenpoa.com/aberdeen/picture/166mass_dispensing_program_consent_form.pdf

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Microsoft word - ~3470279.doc

L’AUTORITÀ GARANTE DELLA CONCORRENZA E DEL MERCATO NELLA SUA ADUNANZA del 14 dicembre 2011; SENTITO il Relatore Dottor Salvatore Rebecchini; VISTA la Parte II, Titolo III, del Decreto Legislativo 6 settembre 2005, n. 206, recante “ Codice del Consumo ” e successive modificazioni (di seguito, Codice del Consumo); VISTO il “ Regolamento sulle procedure istruttorie in materia di prat