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Medical Dispensation Form

Medical Dispensation

 We have indicated that our minor child, __________________________________________ will be using medication while he/she is attending the PRO-ORB Orthodox Winter Service Retreat. 


Please list below in the appropriate columns all Prescription and Over-the-Counter Medication information which the minor youth participant may require during the Winter Service Retreat:      

 

Name of Medication

 

Indications

 

Dosage

 

Times/Day:        Given By:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

     (Please make a checkmark in the appropriate box.)


¨                
I wish the asthma inhaler or epi-pen to be with my Youth Participant at all times.

¨                 I wish the asthma inhaler or epi-pen to be kept with the Youth Retreat Health Officer/Nurse.

If a Youth Participant uses an inhaler to treat asthma, or carries an epi-pen:

Parents Please Note!  If this youth participant has your permission to self-medicate with any or all of the above described prescriptions or over the counter medications, or if a parent will be present and wishes to retain this responsibility, please clearly indicate above in the “Given By” Column. Otherwise, all listed medications will be collected at the beginning of the Youth Retreat to be safely stored and administered by the Retreat’s Nursing Staff. All medications need to be brought to the Retreat and presented to Staff in original packaging and prescription bottles.

 _____________________________________________________________

Signature of Parent or Legal Guardian

 

¬°Gloria a Dios por todo!
Direct your Questions, Comments or Feedback to (Por favor dirigir sus preguntas, dudas o comentarios al): 956-781-6114 or info@stgeorgepantry.org


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