MDH-4758-C: Asthma Action Plan Instructions

*IF YOUR CADET HAS AN ASTHMA INHALER OR ANY ASTHMA-RELATED MEDICATION READ THIS CAREFULLY*

Tri-wing Encampment is required to be licensed by the State of Maryland as a residential camp and as such must follow comply with state regulations regarding the administration of medications during Tri-wing Encampment.

An Asthma action plan (MDH-4758-C) MUST be completed and signed by you AND your Cadet’s health care provider that includes INHALERS and EVERY ASTHMA RELATED MEDICATION that your cadet will or may take during Tri-wing Encampment.

Instructions for Completing the Form:

1. Print this Asthma Action Plan and medication authorization form and have your health care provider complete the dosing instructions for EACH Asthma Medication that your child will or may take during Tri-wing Encampment.

2. Your health care provider MUST COMPLETE AND SIGN page 1, the ASTHMA ACTION PLAN AND page 2, Section II and IV the PRESCRIBER AUTHORIZATION for supervised self-administration and self-carry of an emergency inhaler.

3. A parent/legal guardian MUST COMPLETE AND SIGN SECTION III and IV the PARENT/GUARDIAN AUTHORIZATION to allow supervised self-administration and self-carry of an emergency inhaler.

If you have questions or concerns about medication authorization or administration, please contact vsantos@md.cap.gov