Self-medication Permission

Philadelphia Eagles Youth Football Camps

Camper's 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.

Campers are required to obtain a doctor's signature.

Doctor Signature: _________________________________________________________Date:___________________________

In granting this permission for my child to possess medication and self-medicate, I hereby absolve the Philadelphia Eagles Football Club, Inc, 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.

Please complete the following information.   (Use back side, if necessary):

   Medication Name:

______________________________________________________________________________________

   Dosage: ______________________________________________________________________________________

  Method of administration: ______________________________________________________________________________________

   Frequency and timing of Medication: ______________________________________________________________________________________

   Date of Prescription or Order: ______________________________________________________________________________________

   Other Medical Conditions Requiring Medication: ______________________________________________________________________________________

   Specific Recommendations for Administration:

______________________________________________________________________________________

  Side Effects, Contraindications and Adverse Reactions to be Observed:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________