PARENT PERMISSION FORM
USE OF SELF-ADMINISTERED EMERGENCY MEDICATION
As the parent or guardian of ___________________________________________________, Camper Name during his/her time at camp, the above listed camper is permitted to have readily available (carry or possess outside of the regular supervision of the camps health staff) self-administer
as medically necessary: (Circle all that apply or list other emergency self-medication device.)
a. Asthma Inhaler
b. Epinephrine Pen
c. Other (please list) ___________________________________________________
I have read the State of Maine law as listed below, and confirm that my child has the
knowledge and the skills to safely have readily available and self-administer the indicated
emergency medication in camp.
Parent or Guardian signature _____________________________Date_____________________
PRIMARY HEALTH CARE PROVIDER FORM
APPROVAL FOR SELF-ADMINISTERED EMERGENCY MEDICATION
As the primary health care provider of ___________________________________________, Camper Name during his/her time at camp, the above listed camper is permitted to have readily available (carry or possess outside of the regular supervision of the camps health staff) self-administer
as medically necessary: (Circle all that apply or list other emergency self-medication device.)
d. Asthma Inhaler
e. Epinephrine Pen
f. Other (please list) ___________________________________________________
I have read the State of Maine law as listed below, and confirm that my child has the
knowledge and the skills to safely have readily available and self-administer the indicated
emergency medication in camp.
Heathcare Provider signature _____________________________Date_____________________
Recreational camps for children; emergency medication. A recreational camp for boys or girls must have a written policy authorizing campers to self-administer emergency medication, including, but not limited to, an asthma inhaler or an epinephrine pen. The written policy must include the following requirements:
A. A camper who self-administers emergency medication must have the prior written approval of the campers primary health care provider and the campers parent or guardian;
B. The campers parent or guardian must submit written verification to the camp from the campers primary health care provider confirming that the camper has the knowledge and the skills to safely self-administer the emergency medication in camp;
C. The camp health staff must evaluate the campers technique to ensure proper and effective use of the emergency medication in camp; and
D. The emergency medication must be readily available to the camper.
The full statute may be viewed at:
http://janus.state.me.us/legis/statutes/22/title22sec2496.html
