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MEDICATION WAIVER FOR

TEAM TRAVEL

I, ­­­­_______________________________, swimmer (if 18 years) or parent or guardian of

________________________________ (swimmer’s name), give permission for chaperones traveling with the team to administer the recommended dosage of over-the-counter medication to ______________________ in the event he/she becomes ill while traveling with the team.

I also understand that ______________________ will not share with anyone any over-the-counter or prescription medication that he/she has in his/her possession while traveling with the team.

Please check all that apply:

____ I give permission for over-the-counter medication to be administered to my child.

____ I request to be contacted at __________________ (provide phone no) before administering over-the-counter medication to my child.

____ I do NOT give permission for anyone to administer over-the-counter medication to my child.

____ My child will be administering his/her own over-the-counter and/or prescription medication. Please list:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

____________________________________

Parent/Guardian Signature            Date

____________________________________

Athlete Signature                        Date