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Self-medication Permission

Chicago Blackhawks Youth Hockey Camps

Camperýs Name: _______________________________________________________________________

Camp Location(s), Date(s) ______________________________________________________________

PARENT/GUARDIAN AUTHORIZATION

My child has a physical condition which requires him/her to receive medication as quickly as possible in order to avoid a medical crisis. In the interest of his/her personal well being,

I hereby grant my child the authority to carry his/her medication (medication name)______________________________________________

and to self-administer it as directed by the prescribing physician when needed.

Condition requiring possession of medication and self-medication:___________________________________________________________

The above-named child may possess and use ___________________________________________________________by self-administration. 

He/she has been instructed in its proper possession and use.

In granting this permission for my child to possess medication and self-medicate, I hereby absolve the United Center Joint Venture, an Illinois joint venture, BSV Limited Partnership, CBLS Corporation, Chicago Professional Sports Limited Partnership, Chicago Bulls Limited Partnership, Jerry M. Reinsdorf Revocable Trust, and all beneficiaries thereof, Metropolitan Chicago Stadium Enterprises Limited Partnership, Metropolitan Chicago Stadium Enterprises, Inc., Chicago Stadium Corporation, Arthur Wirtz Family Limited Partnership, Wirtz Corporation, Consolidated Enterprises, Inc., Chicago Blackhawk Hockey Team, Inc., At Your Service, LLC, At Your Service Management Corporation, Standard Parking Corporation, the National Hockey League, USA Hockey, Pro Sports Experience, LLC and all of their respective directors, officers, shareholders, subsidiaries, partners, agents, sponsors, employees, successors, parents, beneficiaries, heirs, executors, administrators, assigns and affiliates thereof (collectively, "Releasees"), from any liability or legal responsibility for any condition that may arise from the administration or lack of administration of such medication.

Parent/Guardian Signature: __________________________________________________Date: __________________________

NOTE: A completed and signed copy of this form must be given to the camp director or health director no later than the first day of camp or on the first day that the child brings the medication to camp.

Pursuant to Illinois law, please complete the following information.   (Use back side, if necessary):

ý Medication Name____________________________________________________________________________________________

ý Dosage_____________________________________________________________________________________________________

ý Method of administration _____________________________________________________________________________________

ý Frequency and timing of Medication______________________________________________________________________________

ý Date of Prescription or Order: _________________________________________________________________________________

ý Other Medical Conditions Requiring Medication: __________________________________________________________________

ý Specific Recommendations for Administration: ___________________________________________________________________

ý Any severe adverse reactions that may occur to another child, for whom the epinephrine auto-injector or inhaler is not prescribed, should the other child receive a dose of the medication.

       
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