Microsoft word - medical information waiver form _rev 18march13_

City of Saco, Maine Parks & Recreation Department M E D I C A L I N F O R M A T I O N & W A I V E R P O L I C Y (18March13)
Participants with medical conditions requiring emergency administration of prescription or non prescription medications are welcome and may participate in all Saco Parks & Recreation Department Programs. If at any time it is found that this policy has not been followed or been kept up to date dismissal from Saco Parks & Recreation programs may result. 1. Program Requirements
a. Check with the Office to verify that the program you are registering for falls under the terms of this b. Requests for emergency medication at a program must be made by completing a Medical Information & c. Medical Information & Waiver Forms are activity-specific and additional forms/medications may be required for activities at different locations. d. All information will be kept confidential and is for the safety and well being of your child, the other children in the program and our staff.
2. Emergency Medication
The Department may train its personnel to administer epi-pens and asthma inhalers for emergency situations.
As part of a Doctor’s written medical action plan, diphenhydramine (Benadryl or equivalent) may also be included for treatment as specified in the written medical plan: the type and dosing of diphenhydramine provided must match that indicated in the action plan. A participant who uses and/or relies upon such emergency prescriptions and devices listed above shall be welcome in a program provided the following conditions are met: a. For PROGRAMS ALREADY IN SESSION: all medications and their labels* with the child’s name, name of medication, date filled & expiration date for epi-pen or asthma inhaler must be provided at least 2 full business days prior to the child participating in one of our programs, provided that adequate advance notice of each program is made available to eligible participants. *Labels can be one of the following formats: 1. a copy of a doctor’s prescription; 2. medication label; OR 3. pharmacy prescription label. b. By choosing option A the parent/guardian is expressly choosing to have the participant administer their own emergency medication. Department staff will only administer emergency medication if the child is unable to do so on their own. For this reason a back up of all medications must be provided to the department under Option A. c. By choosing option B the parent/guardian is expressly authorizing and consenting that the Department administer the medication in the event of an emergency in lieu of their child. Under Option B, your child may not self medicate. d. By choosing option C the parent/guardian opts to waive their choice to have their child self medicate and is also requesting that the Department staff NOT ADMINISTER medication in the event of an emergency. In such cases, the patent/guardian is expressly directing that EMS/911 personnel act as first responders and administer any emergency medication. e. The Department will not allow any other emergency medication other than those indicated above to be held by the child or by Department staff. Page 1 of 3
f. Regardless of which Option is selected, the Department will call upon EMS/911 services and personnel for assistance in any emergency without prior consultation with parent/guardian. 3. Storage of Medication
a. At no time is it acceptable for participants to carry any type of medication on them or in their belongings. i. Exceptions are Epi-pen/Benadryl Tablets or asthma inhaler for emergency use. b. Medication must be dropped off to the Office at least one week prior to the start of the program. c. All medication dropped off by parents must be in the original container from the pharmacy and clearly labeled with the individuals name, prescribed dosage, name of medication, and expiration date. d. The department cannot accept any medication that must be climate controlled. e. The department will store all medication in a secure location only accessible by senior staff. f. Diphenhydramine (Benadryl or equivalent) must be provided in accordance with the medical action plan in premeasured dosages. (We do not accept liquid forms that are not premeasured). 4. Routine Medication
a. The Department and participants will not carry or administer routine medication. b. Parent/guardian will be solely responsible for assuring that they have correctly administered their medications either prior to or during program time. c. If routine medication must be administered during program time, a parent/guardian or designee must come to the program and administer the medication directly. The parent/guardian must give prior authorization of designee to the Department’s Office beforehand. d. In all circumstances, the Department must be made aware on the Participant Contact Form of any medication used by a participant, prior to the admission to any program. This information is vital for emergency medical personnel who may be responding to an emergency situation.
5. 911 Policy
a. In all cases and circumstances, the Saco Parks & Recreation Department will call 911 and Staff will abide by and follow all EMS/911 instructions during a medical emergency concerning your child. The Parent/Guardian will be notified by Parks & Recreation Staff at the earliest opportunity.
6. Expiration & Return of Medication
a. Parents/guardians are responsible for picking up any and all medication at the end of the program. b. If participant is enrolled in another program that starts immediately after the ending program, the current medication and forms (unless otherwise specified) can still be used. c. Parents are responsible for providing updated prescriptions/medications prior to them expiring. Medication must be updated 1 week prior to expiration to allow Department adequate time for distribution. Failure to keep medications up to date will result in immediate suspension of services. d. In all cases parents/guardians are responsible for picking up expired medication. A $50.00 disposal fee will be issued to the household account if the medications are not picked up within two weeks of a program’s end. Page 2 of 3
City of Saco, Maine Parks & Recreation Department M E D I C A L I N F O R M A T I O N & W A I V E R (rev.18MARCH13)
Child’s Name: _________________________________ Medical Condition: _____________________________ Name of Medicine: _____________________________ Prescribing Doctor: _____________________________ Doctor’s Phone #: ______________________________ Program medication is being supplied for: _____________________________________ ALL MEDICATION MUST BE PROVIDED TO SACO PARKS & RECREATION AT LEAST 1 WEEK PRIOR TO THE START OF PROGRAM.

Parent/Guardian must check one of the following, and submit both this form & registration materials to the Office to register.
(A) Self Medication or Administered by Saco Parks & Recreation Trained Staff -IF Child is Unable.
Parks & Recreation MUST be provided with medication, even if child is carrying medication.
(Under this provision, child may carry and self administer their own medication. Medication will be administered by trained
recreation personnel in the event child is not able.)
(B) Child Will Not Self Medicate - Medication Administered by Saco Parks & Recreation Staff
(Medication to be held by P&R Dept & will be administered by trained recreation personnel.)

(C) Waiving Emergency Medication Administered by Saco Parks & Recreation Staff
Parks & Recreation MUST be provided with medication (to be used by emergency medical personnel)
(Emergency Medical Services will be called and dispatched by local 911 service) ~ The following must be provided with this form ~
Copy of Medication Label or Pharmacy Prescription with the child’s name, name of medication, A Doctor’s medical plan must be provided in cases where Epi-Pen is not the first course of action. I, ________________________________, for and on behalf of _______________________, state that I agree to and will abide by this medical policy as set forth above and affirm that my child has received the necessary training if he/she is to self medicate. By signing below I also agree and understand that Saco Parks & Recreation personnel may call 911 for emergency aid and that I will be responsible for those costs and medical expenses that arise as a result of rendering emergency medical aid to my child. In addition I understand that Parks & Recreation Staff will abide by and follow all EMS/911 instructions during a medical emergency concerning my child. ____________________________________ Page 3 of 3

Source: https://sacorec.com/forms/5474_medical_information__waiver_form__rev_8march13_.pdf