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(to be completed by Health Care Provider)

Medications for Allergy

For children requiring rescue medication, the medication is required to be at program site at all times while child is in care. For youth who self-medicate and carry their own medications, medication must be with the youth at all times.

The options of storing “back up” rescue medications at program is available. Field Trip Procedures Rescue medications should accompany child during any off-site activities.

The child should remain with staff or parent/guardian during the entire field trip.

  • Yes No

Staff members on trip must be trained regarding rescue medication use and this health care plan. This plan must accompany the child on the field trip. Other (specify)_________________________________________________________________________

Self-Medication for School Age/Youth

  • YES. Youth can self-medicate. I have instructed _______________________in the proper way to use his/her

medication. It is my professional opinion that he/she SHOULD be allowed to carry and self administer his/her medication. Youth has been instructed not to share medications and should youth violate these restrictions the privilege of self medicating will be revoked and the youth’s parents notified. Youth are required to notify staff when carrying medication.


  • NO. It is my professional opinion that _______________________

his/her medication. Bus Transportation should be alerted to child’s condition.

SHOULD NOT carry or self administer

This child carries rescue medications on the bus.

  • Yes No

Rescue medications can be found in: Backpack Waistpack On Person Other_____________

Child should sit at the front of the bus.

  • Yes No

Other (specify): ________________________________________________________________________

Sports Events

Parents are responsible for having rescue medication on hand and administering it when necessary when the child is participating in any CYS sports activity. Volunteer coaches do not administer medications.

Parental Permission/Consent

Parent’s signature gives permission for child/youth personnel who have been trained in medication administration by the CYS nurse/APHN to administer prescribed medicine and to contact emergency medical services if necessary. I also understand my child must have required medication with him/her at all times when in attendance at CYS programs.

Youth Statement of Understanding

I have been instructed on the proper way to use my medication. I understand that I may not share medications and should I violate these restrictions, my privileges may be restricted or revoked, my parents will be notified and further disciplinary action may be taken. I am also required to notify staff when carrying medication.

Printed Name of Parent/Guardian

Parent Signature


Printed Name of Youth (if applicable)

Youth Signature


Stamp of Health Care Professional

Health Care Professional Signature


Printed Name of Army Public Health Nurse

Army Public Health Nurse Signature


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