Medical Permission Form for the Awake Youth Project Free to Be Me retreat

Based on state laws, Brooklyn Zen Center requires all participants to hand in medication to the retreat staff at the start of the retreat. These medications will be given to the participants based on their prescription, for the participant to self-administer. We require written parental permission (see below) for all medication taken while on retreat.

All medication must be brought in a correctly labeled pharmacy or manufacturer’s medication container. Medications will not be accepted in containers such as plastic bags or daily pillboxes. Medications will be distributed exactly as the container instructs. Please send enough medication to cover the duration of the retreat.

All medications will be kept by an retreat staff member in a secure location and returned to the participant at the close of the retreat.
**Inhalers/Epi-pens: If your child has asthma or life-threatening allergies, with your permission, they will be allowed to keep these on their person at all times. However, we request that you also send in an extra inhaler or Epi-pen to be kept with retreat staff as an additional safety precaution.

Name *
Name
Does your family have medical insurance? *
Does your teen have any allergies? *
Does your teen currently take any medications? *
PARENT SIGNATURE: I (signature below) grant permission for my teen to self-administer their own medication (listed above) while on the Awake Youth Project retreat. Additionally, I agree to release, indemnify, and hold harmless Brooklyn Zen Center, the Brooklyn Zen Center Board of Directors and all Brooklyn Zen Center employees, volunteers, and other agents, from and against any claim either my child or I may have as a result of any act or omission, which may arise out of this authorization.
PARENT SIGNATURE: I (signature below) grant permission for my teen to self-administer their own medication (listed above) while on the Awake Youth Project retreat. Additionally, I agree to release, indemnify, and hold harmless Brooklyn Zen Center, the Brooklyn Zen Center Board of Directors and all Brooklyn Zen Center employees, volunteers, and other agents, from and against any claim either my child or I may have as a result of any act or omission, which may arise out of this authorization.
Date *
Date