AUTHORIZATION TO ADMINISTER MEDICATION

(TO BE KEPT CONFIDENTIAL UPON COMPLETION)

NAME OF PLAYER: _____________________________________________

DIAGNOSIS/ILLNESS: ____________________________________________

MEDICATION: __________________________________________________

DOSAGE: ______________________ FREQUENCY: ___________________

SPECIAL DIRECTIONS:____________________________________________

POSSIBLE SIDE EFFECTS: _________________________________________

I certify that the above information regarding this player is correct, and that administration of the medication to this Player is necessary.

_________________________________________ _______________________

(Signature of Prescribing Physician) (Date)

________________________________________ _______________________

(Address) (Phone)

I/We authorize SAYSO to administer the above medication as indicated in my absence at practices, games, tournaments, and other events (e.g., field trips). I/We understand and agree that SAYSO, its employees, designated agents, directors, and volunteers shall not be liable for any injury to the Player resulting from the administration of the medication as authorized by my signature below.

_____________________________________

(Signature of Parent/Guardian)

___________________________________________

(Signature of Parent/Guardian)

___________________________________________

(Date)