MDH-4758-B: Medical Authorization Form Instructions

*IF YOUR CADET TAKES ANY PRESCRIPTION OR OVER –THE-COUNTER MEDICATIONS READ THIS CAREFULLY*

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

A Medication Authorization Form (MDH-4758-B) MUST be completed and signed by a Parent/Guardian AND your cadet’s health care provider. The form must include EVERY MEDICATION that your child will or may take during encampment.  This includes all prescription, vitamins/homeopathic/herbal medications, and over-the-counter medications.

Instructions for Completing the Form:

1. Print the Medication Administration Authorization Form and have your health care provider complete the dosing instructions for EACH prescription AND over-the-counter MEDICATION that you child will or may take during Tri-wing Encampment.

2. A parent/legal guardian MUST COMPLETE AND SIGN "SECTION II. PARENT/GUARDIAN AUTHORIZATION" to allow supervised self-administration of medications.

3. Your health care provider MUST COMPLETE AND SIGN "Section I: PRESCRIBER AUTHORIZATION".

4. If your child has a severe allergy that requires an Epi Pen, your health care provider MUST COMPLETE AND SIGN "SECTION III: AUTHORIZATION FOR SELF-ADMINISTRATION / SELF-CARRY".

   1. A parent/guardian MUST also COMPLETE AND SIGN Section III. This will allow your cadet to carry the Epi-Pen at all times.

5. If your child has asthma or wheezing that might require an emergency inhaler print out the form titled Asthma Action Plan. This plan must be COMPLETED AND SIGNED by a parent/guardian and your health care provider. Please see separate instructions for this document.

If you have questions or concerns about medication authorization or administration, please contact vsantos@md.cap.gov and the appropriate cadre member will contact you.