Upward Bound - Medical Release 2024

This Medication Release Form covers the entirety of the Upward Bound Summer Program for the year listed above. Students under the age of 19 are not allowed to administer medication to themselves, under the supervision of the Upward Bound program. This form helps us prepare medication administration schedules, so that we can document when students are taking medication on the reverse side of this page, which helps in the event of an emergency. We will not give a student any medication if you have not authorized us to. UB staff tries their best to make sure students are taking their medication, but it is ultimately up to the student to make sure they get their medication when they are supposed to.

Student's Name Student's Name First Last
Today's Date Today's Date / MM / DD YYYY
Non-Prescription (As-Needed) Medication:
I authorize the Upward Bound staff to give my child pain medication as needed, such as any brand of aspirin or ibuprofen, and motion sickness medication.

I authorize the Upward Bound staff to give my child pain medication as needed, such as any brand of aspirin or ibuprofen, and motion sickness medication. Yes No
Prescription Medication & Routine Medication (Including Allergy, Sleep Aids, Vitamins, Etc.):
Is your child taking any prescriptions?

Is your child taking any prescriptions? Yes No
Please list all prescriptions. For each, include the following:
-Name of medication
-Reason for taking medicine
-Dosage
-# of times per day
-Time(s) typically taken
-Name of medication: -Reason for taking medicine: -Dosage: -# of times per day: -Time(s) typically taken:
Signature of parent / guardian:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Upward Bound - Medical Release 2024

Upward Bound - Medical Release 2024

Non-Prescription (As-Needed) Medication:

Prescription Medication & Routine Medication (Including Allergy, Sleep Aids, Vitamins, Etc.):