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YMCA of Western North Carolina: Medication Information

This form is used by the YMCA of Western North Carolina for children who need prescription medication or have special needs while in their programs. It collects information about the child's prescription including medication name, dosage, and instructions. Parents must authorize the YMCA staff to administer the medication and contact the healthcare provider if needed. For children with special needs, parents explain the need so staff are prepared. The YMCA aims to include all children but may not be able to for those requiring fundamental program changes or posing a safety risk to others.

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12 views

YMCA of Western North Carolina: Medication Information

This form is used by the YMCA of Western North Carolina for children who need prescription medication or have special needs while in their programs. It collects information about the child's prescription including medication name, dosage, and instructions. Parents must authorize the YMCA staff to administer the medication and contact the healthcare provider if needed. For children with special needs, parents explain the need so staff are prepared. The YMCA aims to include all children but may not be able to for those requiring fundamental program changes or posing a safety risk to others.

Uploaded by

ymcawnc
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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YMCA of Western North Carolina

Child Care Services Branch Individualized Care Plan Form


This form will be utilized when a parent/guardian has indicated on the Youth Information Form that their child will be
taking a prescription medication, has a special need and/or disability while participating in the YMCA program.
_______________________________________________________________________________________________________

MEDICATION INFORMATION:
CHILDS NAME: ________________________________________________ CHILDS DATE OF BIRTH ___________________
Name of Prescription Medication to be taken at the YMCA:_____________________________________________________
Expiration Date: _____________ Time to Be Taken and Frequency: ______________________________________________
Dosage Amount: ____________Beginning Date: _______________________ Ending Date: ___________________________
Special Instructions:______________________________________________________________________________________
______________________________________________________________________________________________________

Possible Reactions: ____________________________________________________________________________________


_____________________________________________________________________________________________________
Prescribing Provider: ____________________________________________ Phone: ________________________________
Pharmacy: ____________________________________________________ Phone: ________________________________
I give the YMCA staff authorization to give medicine noted above and to call the health care provider if needed.
Parent/Guardian Signature: _________________________________________________________ Date: __________

SPECIAL NEED/CONCERN/DISABILITY:
If you listed a special need or medication on the previous sheet, please explain so our staff are familiar prior to your
child attending program:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
If the YMCA staff and/or the parents/guardians feel it is necessary, a meeting will be scheduled in advance to discuss
specific information. The YMCA program welcomes all children to the extent that it is reasonably able to do so. A child
who requires measures that constitute a fundamental alteration to the program or other undue hardship, or a child that
poses a direct threat to the health and safety of others, will not be able to participate in the program. All children,
regardless of their circumstances, are subject to YMCA disciplinary procedures.
_______________________________________________________________________________________________________
Office Use Only: ____YMCA is to contact family regarding admission into camp
____ Parent requests contact with YMCA staff prior to camp

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