Self-Administration of Medication Policy and Consent Form You have requested that a prescription or over-the-counter (OTC) medication be taken at Carnegie Museums of Pittsburgh Summer Camps. If medication can be given at home, before or after your child’s participation in the camp, please do so. All medication taken at Carnegie Museum’s Summer Camps must have parental consent for administration and must be self-administered by the camper (or administered by, or with the assistance of, the camper’s parent or other adult designated by the parent). Any camper in possession of or taking medications not previously approved by a parent/guardian and camp staff will need to be immediately sent home from Summer Camps until such time as necessary approvals have been provided. Summer Camp staff are not permitted to administer any medications to campers. In the event of an emergency, 911 will be called. In the event of an emergency requiring the administration of a camper’s personal Epinephrine Auto Injector, the Epinephrine Auto Injector will be administered to that camper in accordance with the Carnegie Museums of Pittsburgh Epinephrine Auto Injector Policy provided that the camper’s parent/guardian has signed that Policy. Please Note: Carnegie Museums does not provide Epinephrine Auto Injectors at its camps. They must be supplied, as needed, with each camper in accordance with Carnegie Museum’s Epinephrine Auto Injector Policy.1. The parent/legal guardian must identify below the medication(s) his/her child (or the parent or other adult designated by the parent) will be administering. Prescription medication(s) MUST be labeled by a physician or pharmacist and include the child’s name. Over-the-counter medication(s) MUST be in the original container and labeled with the child's name.List Medications * RequiredName of MedicationDate of PrescriptionDiscontinue Date Reason for medication(s) * RequiredReason that necessitates the medication(s) be given during camp hours * RequiredDaily? * RequiredYesNoPRN (as needed)EmergencyRoute of administrationIntended effect of each medication(s)Side effects (from each medication(s)) student should be observed forDirections for self-administration2. The camper must be capable of identifying when the medication(s) is required and know how to use the medication(s) appropriately. Campers will be responsible for holding and administering their medication(s) completely on their own or with the assistance of a parent or other adult designated by the parent for this purpose (i.e. our staff cannot give reminders or administer the medication(s)). If the camper is not old enough or unable to hold/administer their medication(s), the parent or other adult designated by the parent, must visit camp to administer the medication(s). Please check applicable box below. * Required My child will self-administer the medication(s) during camp. Parent/legal guardian will administer the medication(s) during camp. I designate the following individual, who is 18 years of age or older, to administer the medication(s) to my child during camp: Name First Last PhoneRelationship to Child3. The camper must not under any circumstances share his/her medication(s) or involve another camper in the self-administration of that medication(s). 4. The camper must use the medication(s) only as prescribed. 5. The camper must notify a Summer Camp staff member if and when the medication(s) is self-administered. 6. The parent/legal guardian agrees to accept full liability for injuries related to inappropriate use of the medication(s) by the camper. 7. The parent/legal guardian agrees to notify Carnegie Museums Summer Camps immediately of any medication changes.Parental Waiver of Liability I hereby acknowledge that I am primarily responsible for administering medication to my child/minor for whom I am legally responsible. However, in my absence, I hereby authorize my child/minor for whom I am legally responsible to administer the above described medication(s) to him/herself or for the medication(s) to be administered by the adult I have designated above. I also authorize Carnegie Museums personnel to administer medication in the event of an emergency as set forth above. I, for myself and my child/minor for whom I am legally responsible and our heirs, next of kin, executors, assigns and insurers, hereby irrevocably and unconditionally release, waive and covenant not to sue and agree to indemnify and hold harmless Carnegie Institute d/b/a Carnegie Museums of Pittsburgh (the “Museum”) and its employees, volunteers, staff and all others acting with or for the Museum, from and against any and all claims, causes of action, losses, costs (including legal fees), damages and liabilities for any and all injuries or other types of harm arising out of or relating to the administration of said medication(s) to my child/minor for whom I am legally responsible while participating in Carnegie Museums of Pittsburgh Summer Camp and any and all associated programming. I represent that I am over 18 years of age and have full authority to enter into this Waiver of Liability. Pennsylvania law shall apply to this Waiver of Liability and jurisdiction and venue for all controversies or claims relating to this Waiver of Liability or the said administration of medication shall be Allegheny County, Pennsylvania. I agree to the conditions and waiver of liability above:Name of Camper * Required First Last Birth Date - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Name of Parent/Guardian First Last Emergency Phone * RequiredSignature of Parent/Guardian * RequiredDate - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.