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Microsoft word - troop 641 over the counter med auth.doc
BSA TROOP 641 OVER THE COUNTER MEDICATION AUTHORIZATION
This form authorizes registered adult leaders of Boy Scout Troop 641 to dispense “over the counter” (non-prescription) medications to scouts under their
supervision if in their judgment it is appropriate. Execution of this form is voluntary; however, under BSA policy, adult leaders are prohibited from
dispensing medications to scouts without parental approval, so if this authorization is not provided, no medications of this type will be given to your son unless you can be contacted to give specific permission. THIS FORM IS NOT FOR PRESCRIPTION OR REGULARLY ADMINISTERED
MEDICATIONS. If your son needs to take medications at a scout function, a separate form is available for that purpose. Please see FAQ on reverse for
DRUG ALLERGIES: Please list all drug allergies.
AUTHORIZATION: READ CAREFULLY.
I hereby authorize any registered adult leader of Boy Scout Troop 641 (“Leader”) to dispense to
my above named son the medicines indicated by my initials below or if I initial the last line, all medications listed below. Unless stated
otherwise in the limitations/special instructions sections below, these medicines may be administered in the discretion of a Leader for causes
or conditions indicated on the labeling for the product, in the dosages stated on the labeling for a boy of the age/size of my son. This
authorization shall remain valid for one year from the date shown below. INITIALS MEDICATION
Pain relief. Acetaminophen. (Tylenol® and generics)
Ibuprofen. (Motrin®, Advil® and generics)
Diphenhydramine Hydrochloride. (Benadryl® and
generics) Histamine blockers for allergic reactions.
Antacids. Calcium Carbonate, Magnesium Hydroxide Some of these products not labeled for children under 12. and/or Aluminum Hydroxide (Tums®,
Dispense products with label limitations anyway?
Mylanta®, Maalox® and other antacids contain some or
all of these substances and in some cases other ingredients, such as gas reducers.
Bismuth Subsalicylate. Pepto-Bismol® Kaopectate® and
Not labeled for children under 12. Dispense anyway?
Motion Sickness Remedies. Dimenhydrinate
Meclizine hydrochloride not labeled for children under 12.
(Dramamine®), Meclizine hydrochloride (Bonine®
Topical “first aid” products. (Neosporin®, triple antibiotic, Bactine®, and similar products containing antiseptics, antibiotics and/or topical pain relievers).
Topical antiseptics and scrubs, including povidone-
iodine (Betadine® and generics), alcohol, Chlorhexidine (Hibiclens®) and hydrogen peroxide.
Topical Burn/Sunburn Relief Products. Creams and gels, including aloe vera and other products labeled as providing relief for minor burns and/or sunburn.
Topical Hydrocortisone. (Cortaid® and generics)
Topical Diphenhydramine Hydrochloride. (Benadryl® Itch Relief and generics).
Topical Medicated Powders. (Ingredients include menthol, zinc oxide, talcum powder, corn starch, etc.)
Swimmer’s Ear Prevention Drops. (Alcohol/Vinegar mixture and similar products)
Topical Bite/Toxin neutralizers. Meat tenderizer, AfterBite® etc. Contain ammonia, baking soda papain, vinegar and/or other ingredients to neutralize toxins.
Tincture of Benzoin (Used on skin adjacent to cuts to improve adhesion of bandages or steri-strips®)
ALL OF THE ABOVE
I hereby certify that I have read and understand this document and that I have the authority as parent or guardian of the above minor to authorize the giving of medication to him: Name
Contact Numbers (primary and alternate(s) in the event a leader wishes to discuss medications.
Frequently Asked Questions
• Why am I being asked to sign this form?
The Boy Scouts of America prohibit Registered Adult Leaders (Scoutmaster,
Assistant Scoutmasters, Committee Members) from administering any medication whatsoever to a scout without parental permission. Experience has shown that from time to time, scouts will need first aid or medication for minor conditions. Signing this form provides that permission without making us find you first.
• What if I don’t sign?
Signing the form is entirely voluntary. If you choose not to, your son will not be given any type of
medicine without your express permission. For example, if your son has a sunburn, we will not be able to give him anything for it until we contact you. Sometimes, we are out of communication range, or even though within range, are unable to reach a parent. So, that means that needed medication could be delayed or prevented altogether, prolonging discomfort for your son. In some cases, as with bite toxin neutralizers, prompt administration is essential for the medication to have effect.
• Who decides whether my son needs something?
This form gives any registered adult leader of the troop permission to
give medication to your son. It is the practice of the troop for the Scoutmaster or other adult leader in charge of an event to be consulted in the event of illness or injury to a scout, but other registered leaders may use their discretion to administer medications when the leader in charge is not readily available. This form does not give permission for any parent who may be attending an event to give medication to your son. It is restricted to registered adult leaders.
• What does “topical” mean?
That is something that goes on the skin rather than in the mouth.
• What about products not labeled for children under 12?
Some products, such as Pepto-Bismol®, contain ingredients the
FDA has determined should not be given to children under 12 without consulting a physician. If your child is under 12, we will not dispense these medicines unless you check the box or insert a special instruction saying that it is OK.
• What if I want a call first?
If you want a call before any medication is given to your son, 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 scraped knee, but want a call before your son 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
• How do you know my son really needs medication?
Sometimes we don’t know for sure. From time to time, boys will
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 will seek to determine and address the source of the symptoms, most of us are not doctors or mindreaders and must rely on our first aid training, experience and judgment. If a boy reports a headache and you have authorized acetaminophen, we may give him a dose, even if we are unable 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 will call a parent.
• What if my son is really sick or hurt?
Expect a call. If a boy has a fever, vomiting or other significant symptoms or
injuries, we will call a parent and/or seek appropriate professional medical care in accordance with the other medical authorizations you have executed. Again, this form is only for over the counter medications.
• My son has an inhaler for asthma attacks or takes prescription medicine. Is this the form for that?
No. This form is
for unanticipated needs for over the counter medicine. If your son has regularly prescribed medication that must be
administered during a scouting activity, or has special medication that must be administered on an as needed basis, you need
to provide the medication and a separate permission/instruction sheet to the adult leader in charge of the event when you drop
off your son. Don’t just give it to any adult going on the trip or to your son to turn in. To ensure proper accountability
and that your son gets the medication he needs, you must turn the medication and form in to the adult leader in
charge or the adult leader expressly designated by the adult leader in charge as the person responsible for medication
for that event.
• What if a medication is not on the list?
If the medication, its generics or its category are not on the list, we will not give it
to your son without calling you. If you think we missed something that should be on the list, let us know.
• What if I still have questions?
Ask the Scoutmaster.
Clinical Consultation Thank you for taking the time to fil out this intake form. Please feel free to put question marks next to any sections that you have questions about, and answer only those areas you are comfortable answering. During the consultation we wil go over this form together. PLEASE PRINT CLEARLY Intake Form Name Are you currently seeing another practitioner?If yes, please p
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