TROOP 420 MEDICATION FORM (ver 3-12)

Activity Name / From Date / To Date
Scout Name (Last, First) / DOB / Weight
Primary Contact Name & Phone Number(s)
Secondary Contact Name & Phone Number (s)
Allergies: Please list all known allergies to prescription and nonprescription medications, food, and environment (e.g., poison ivy, dust):

Please list all prescription medication and non prescription (OTC) medication that your scout is

taking or may need to take if a known condition arises (e.g., allergies develop give Claritin,bee sting requires epi pen)by dosage, when it should be taken and any special instructions. This includes immediate use and potentially lifesaving medications (e.g., Epi pens, inhalers). Follow Instructions below for packaging and labeling medication.

Enter Dosage for Approximate Time
Medication Information
Drug name, dosage, any special instructions / Breakfast
(8:00) / Lunch
(12pm) / Dinner
(6 pm) / Bedtime
(10 pm) / Other
EXAMPLES - Amoxicillin - 1 pill, twice daily, take with food, / 1 pill / 1 pill
Special Instructions: Example if allergy symptoms develops, give Claritin 2x daily
I, the parent (legal guardian) of the above scout authorize the giving of medication as indicated above. I will not hold the dispensing individual, Troop 420, or Boy Scouts of America liable for administering or not administering the medication, or any adverse/ allergic reactions my son may have. This form remains in effect until the end of the activity.
Name:______Signature: ______Date:______

Why am I being asked to provide and sign this form?

Current BSA POLICY: The taking of prescription medication is the responsibility of the individual taking the medication and / or that individual’s parent or guardian. A Scout leader, after obtaining all necessary information, can agree to accept the responsibility of making sure a Scout takes the necessary medication at the appropriate time, but BSA policy does not mandate nor necessarily encourage the Scout leader to do so.

The policy of Troop 420 is ”All medication, prescription and nonprescription, that your son is currently taking, or may take as a result of an illness or injury, will be dispensed by the designated adult in charge of medication.” This approach will make it easier to keep track of the Scouts illnesses, injuries and medications they are taking. If the adult in charge of medication is not available, an adult leader (not any adult) may assume his duties

The onlyexception to dispensing medication is medication that may be needed for immediate and potentially lifesaving use (e.g., Epi pens, inhalers), that will remain with your son. If he uses this medication, he should immediately inform the designated adult in charge of medication, or if he is not available, another adult.

INSTRUCTIONS FOR PROVIDING MEDICATIONS

  • Following the Troop 420 policy, parents should provide their son’s prescription and nonprescription medication he is currently taking,or may need to take if a known condition arises (e.g., allergies develop give Claritin, bee sting requires epi pen)
  • Complete the Troop 420 Medication form providing the requested information for prescription and nonprescription medication he is currently taking,or may need to take if a known condition arises (e.g., allergies develop take Claritin, bee sting requires epi pen). Immediate use and potentially lifesaving medications (e.g., Epi injector pen, inhalers) should also be listed.
  • A parent should give the completed Troop Medication Form with the medication packaged properly as indicated belowto the designated adult in charge of medication when assembling to leave for an activity. He will review the medication and information with you.
  • All prescriptions medicines must be Physician authorized
  • Any nonprescription medicine should be acceptable for use with any prescription medication the scout is taking, and vice versa. You may want to check with the prescribing physician or a pharmacist. Consider if you need to change the Troop 420 OTC Medication Form for Unplanned Use.

Package the medicine properly

  • All prescription medications must be packaged in its original container with label affixed containing medicine name, date, physicians name, pharmacy name, pharmacy contact information
  • All nonprescription medicine must also be in original container with label
  • Only include sufficient medicine for the duration of the trip or activity (The troop will not be responsible for any excess medication that is lost, damaged, or becomes inactive).
  • Place the medicine in one zip-lock bag with the scouts name written clearly in water proof marker
  • Immediate use and potentially lifesaving medications (e.g., Epi pens, inhalers), should not be turned in and will remain with your son. It is recommended that you provide duplicate potentially lifesaving medication packaged as described above to the adult in charge of medication in the event your son loses his medication.