Medication Form1To be completed prior to weekend2To be completed after weekend**For ALL Candidates (regardless of age) & Team Members under 19 years old on the data of the weekend**BVN Weeked Start Date* MM slash DD slash YYYY FIrst day of weekendBVN Weeked End Date* MM slash DD slash YYYY Last day of weekendWeekend Attending* Young Women's Young Men'sPlease make a selection below:* I am a Candidate this weekend I am a team member this weekendAge of Candidate/Team Member* Under 19 Over 19Candidate/Team Member Name* First Last Candidate/Team Member Phone*Candidate/Team Member Email* Enter Email Confirm Email Parent/Guardian Name* First Last Parent/Guardian Phone*Parent/Guardian Email* Enter Email Confirm Email InstructionsPlease complete this form for ALL MEDICATIONS your candidate/team member will be taking as needed at BVN weekend including over the counter medications or cold, inhalers, ect. NOTE: This form must accompany your candidate/team member to BVN weekend only if he/she is taking any medication. Please read the following information related to the "Medication Policy" for BVN. Your signature below indicates that all information provided on this form is correct and that you understand the BVN medication policy.Medication PolicyPlease follow the directions below:* All Medications (over the counter and/or prescription) must be submitted to the Medical Cha upon check in on Friday. The Medical Cha will be a nurse, state licensed EMT or otherwise medically trained person who will be on the campground throughout the entire weekend. All Medication MUST be in the ORIGINAL CONTAINER. If the MEDICINE is PRESCRIBED BY A DOCTOR it must have the CANDIDATE/TEAM MEMBER'S NAME PRINTED on the bottle with dosing instructions. Zip-lock bags, pillboxes, non-original medicine bottles, or any other type of container besides the original WILL NOT BE ACCEPTED. THE DOSAGE INSTRUCTIONS LISTED ON THE BOTTLE MUST BE FOLLOWED unless there is a written note from the prescribing doctor outlining different indications.THERE WILL BE NO EXCEPTIONS TO THIS POLICYMedicationsMedicationName of MedicationDoseReason for TakingAny adverse reactions possibleSpecial Instructions For addition medications that can be taken at the same time of day, please click plus sign on the right of the row to list additional medication.Time Taken As Needed Breakfast Lunch Bedtime DinnerMedicationName of MedicationDoseReason for TakingAny adverse reactions possibleSpecial Instructions Time Taken As Needed Breakfast Lunch Bedtime DinnerMedicationName of MedicationDoseReason for TakingAny adverse reactions possibleSpecial Instructions Time Taken As Needed Breakfast Lunch Bedtime DinnerMedicationName of MedicationDoseReason for TakingAny adverse reactions possibleSpecial Instructions Time Taken As Needed Breakfast Lunch Bedtime DinnerMedicationName of MedicationDoseReason for TakingAny adverse reactions possibleSpecial Instructions Time Taken As Needed Breakfast Lunch Bedtime DinnerFor any addtional medication please add the information below:My signature below indicates I have read and understand the BVN Medication Policy above; and I authorize the BVN Medical Cha to dispense the above medication(s) to the candidate/team member listed above.Parent/Guardian's Signature*Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Candidate/Team Member Signature*Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Medication Release for CandidatesTo be signed when picking up candidateMy signature below indicates I have picked up all medications from the BVN Medical Cha following completion of the BVN weekend.Reset signature Signature locked. Reset to sign again Parent/Guardian SignatureDate MM slash DD slash YYYY My signature below indicates I have picked up all medications from the BVN Medical Cha following completion of the BVN weekend.Reset signature Signature locked. Reset to sign again Candidate Signature if over 19Date MM slash DD slash YYYY My signature below indicates the parent or guardian has picked up all medications from the BVN Medical Cha following completion of the BVN weekend.Reset signature Signature locked. Reset to sign again BVN Medical ChaDate MM slash DD slash YYYY Medication Release for TeamTo be signed when picking up candidateMy signature below indicates I have picked up all medications from the BVN Medical Cha following completion of the BVN weekend.Reset signature Signature locked. Reset to sign again Parent/Guardian SignatureDate MM slash DD slash YYYY My signature below indicates the team member, parent, or guardian has picked up all medications from the BVN Medical Cha following completion of the BVN weekend.Reset signature Signature locked. Reset to sign again BVN Medical ChaDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
