Microsoft word - otc medication form -- 06 2013 1.docx

CREW 905 OTC Medication Form (ver. 06.2013.1)
Venturer Name (Last, First)
Parents Contact Numbers:
ALLERGIES: Please list all known allergies to prescription and non-prescriptions medications, food and the
environmental (e.g., poison ivy, dust):
AUTHORIZATION: I hereby authorize the designated adult in charge of medications or an adult leader of Boy Scout Crew 905 to dispense
to my above named youth the medicines indicated by my initials below, or if I initial the first line, all medications listed below. Unless stated
otherwise in the limitations/special instructions sections below, these medicines may be administered at the discretion the designated adult to
dispense medication, or the leader for causes or conditions indicated on the labeling for the product, in the dosages stated on the labeling for a
youth of the age/ weight of my child.
OTC Medication
Initials
Limitations/ Special Instructions
 Al of the medications listed below
 No limitations
PAIN RELIEF: Acetaminophen (e.g., Tylenol and generics),
Ibuprofen (e.g., Motrin, Advil, and generics), Naproxen sodium
(e.g., Aleve and generics)
DECONGESTANT: Phenylephrine HCl, Pseudoephedrine (e.g.,
Sudafed, and generics)
ANTIHISTAMINE: Diphenhydramine (Benadryl and generics)
Loratadine (e.g., Claritin and generics), Chlorpheniramine
maleate,
ANTIDIARRHEA: Pepto Bismol and generics, Imodium and
generics
ANTIACIDS/ ACID CONTROLLERS: Calcium Carbonate,
Magnesium Hydoxide, and/or Aluminum Hydroxide (e.g., Tums,
Rolaids, Mylanta, Maalox), and others containing some or al of
these ingredients, and generics) ,
MOTION SICKNESS TREATMENT: Dimenhydrinate (e.g.,
Dramamine and generics), Meclizine hydrochloride (e.g., Bonine
and generics)
TOPICAL ANTISEPTICS AND SCRUBS: Povidone iodine (Betadine
and generics), Hydrogen peroxide, Cholohexidine (Hibiclens) and
other general antiseptics
TOPICAL ANTIBIOTICS: Neosporin, Bactine, triple antibiotics
(including generics)and similar products contains antibiotics with
or without topical pain relief
TOPICAL BURN/ SUNBURN RELIEF: Creams and Gels including
aloe vera and other products labeled as providing relief from
minor sunburn and burns
TOPICAL ITCH / RASH RELIEF: Hydrocortichilde (Cortaid and
generics), Diphenhydramine Hydrochloride (Benadryl Itch Relief
and generics), Calamine Lotion, Loratadine (e.g., Claritin and
generics)
TOPICAL MEDICAL POWDERS: Gold Bond and others -
Ingredients include menthol, zinc oxide, talcum powder, corn
starch etc. for itch relief
TOPICAL BITE/ TOXIN NEUTRALIZERS:
Meat tenderizer, After Bite, (containing ammonia), baking soda,
papain, vinegar, and/or other ingredients to neutralize toxins)
I, the parent (legal guardian) of the above scout authorize the giving of medication as indicated above. I wil not hold the
dispensing individual, Crew 905 , or Boy Scouts of America liable for administering or not administering the medication, or
any adverse/ al ergic reactions my child may have. This form remains in effect until withdrawn by the parent.
Name:______________________________ Signature: __________________________Date:____________
QUESTIONS & ANSWERS FOR CREW 905 OTC MEDICATION FORM
• Why am I being asked to sign this form?
Current BSA policy states: The taking of prescription medication is the responsibility of the individualtaking the medication and/or that individual’s parent or guardian. A leader, after obtaining al the necessary information, can agree to accept the responsibility of making sure a youth takes the necessarymedication at the appropriate time, but BSA does not mandate or necessarily encourage the leader to do The policy of Crew 905 is ”Al medication, prescription and nonprescription, that your child is currently
taking, or may take as a result of an illness or injury, wil be dispensed by the designated adult in charge of
medication. This approach will make it easier to keep track of the Scouts il nesses, injuries and medications they
are taking.
Sometimes on overnight trips or longer activities, a scout can develop a minor il ness or condition (e.g., head cold, upset stomach, insect bite, sunburn). He/she may benefit from using nonprescription – over the counter (OTC) - medication. A Crew OTC Medication Form allows parents the
option to specify if their child can receive selected nonprescription, OTC medication.”
Regardless, if the OTC Medication Form is completed or not, an attempt wil be made to contact the parents and discuss the minor il ness or condition, except if the condition is very minor (e.g., minorwound, minor sunburn) and you have given prior permission for treatment on the OTC Medication Form.
However, the crew may be in a location where contact with the parents is not easily accomplished, or notpossible (e.g., no cel phone signal)or the parents may not be reachable. Completing the OTC Medication Form could allow your child to receive OTC medications if selected by the parent and in the judgment of the
adult leader in charge of medication, is appropriate for the condition. We recommend that at a minimum
you provide authorization to treat minor conditions.
How long does this form remain in effect? Unlike the Crew Medication Form, the OTC
Medication Form remains in effect until withdrawn by the parent. Note: Any non-prescription 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. Please review the OTC form if your child starts a prescription medication • What if I don’t sign? Signing the form is entirely optional and voluntary. If you choose not to sign, your
child wil not be given any type of OTC medicine without your express permission.
• What if I want a cal first? If you want a call before any medication is given to your child, don’t sign this
form. If you want a call for some situations but not others, for example, no call for triple antibiotic
ointment for a minor cut, but want a call before your child is given an histamine blocker like Benadryl®,make a note to “call first” in the limitations/special instructions section for that medication.
• What if I want a reduced dosage from what is on the label? Please note this in the limitations/special
instructions section for that medication.
• Who decides whether my child needs something? This form gives the designated adult in charge of
medications or any registered adult leader of the crew permission to give OTC medication to your child. Itis the policy of the crew for the Advisor and adult leader in charge to be consulted in the event of il ness or injury to a Scout. If the adult in charge of medication is not readily available, an adult leader (not any adult)may use his/her discretion to administer medications. This form does not give permission for any parent who may be attending an event to give medication to your child. It is restricted to registered adult leaders asdefined in the Crew Policy.
• How do you know my child real y needs medication? Sometimes we don’t know for sure. From time to
time, Scouts wil report both real and imaginary ailments. Sometime, the real problem is homesickness.
Sometimes, there are other causes. For example, headaches can be the result of dehydration or sunburns. While we wil seek to determine and address the source of the symptoms, most of us are notdoctors or mind-readers and must rely on our first aid training, experience and judgment. If a Scout reports a headache and you have authorized acetaminophen, we may give him a dose, even if we areunable to objectively verify he has a headache or determine a potential cause, to see if that solves the problem. If it does not and significant complaints persist, we wil call a parent.
• What if my child is real y sick or hurt? Expect us to contact you. If a Scout has a fever, vomiting or
other significant symptoms or injuries, we wil call a parent and/or seek appropriate professional medical
care in accordance with the other medical authorizations you have executed in the BSA Annual Healthand Medical Record/ BSA Permission Form. This form is only for non-prescription and OTC medications.
• What if a medication is not on the list? If the medication, its generics or its category are not on the list,
we wil not give it to your child without calling you. If you think we missed something that should be onthe list, let us know.
What if my child does not want to use the medication? We wil try to contact you and advise you
that he does not want to use the medication we think he needs.
• What does “topical” mean? That is something that goes on the skin rather than in the mouth.
• My child has an inhaler for asthma attacks or takes prescription medicine or non-prescription
medicine if a know condition arises. Is this the form for that? No, this form is for unanticipated needs for
non prescription, OTC medicine. If your child has regularly prescribed or non-prescription medication that
must be administered during a Scouting activity, or on an as-needed basis, this information must beincluded on his/her BSA Health and Medical Record form, and on Crew 420 Medication Form.
• What if I stil have questions? Ask the Crew Advisor or Committee Chair.

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