2023 Summer Camp Medical Form Instructions
BSA standards and state laws require accurate medical records for campers and staff. They are also critical to
ensure timely, effective care should you or your Scout become sick or injured while at camp. All campers, adult
leaders and staff MUST complete the BSA Annual Health and Medical Record form annually. Forms expire after the
last day of the 12
th
calendar month from the physical exam date.
Without a completed medical form, Scouts, leaders, parents, and visitors WILL NOT PARTICIPATE in many
camp activities including (but not limited to) swimming, boating, climbing, COPE, and sports, and may not
remain in camp longer than 72 hours.
Read the medical form carefully. The next page highlights areas that are commonly incomplete. Please note the
following:
Part A
This page contains an important risk advisory, informed consent, and release. Please read this advisory carefully.
The participant and parents (if participant is under 18) must sign to acknowledge agreement with the information
on this page. This page also includes space to list adults who are authorized (or prohibited) to take this participant
to/from events.
Part B
Part B contains the participant’s contact and insurance information and general health history. Page 2 of this
section contains information about medication and allergies. Please complete these sections carefully and
accurately. The parents and health care professional must sign to authorize all medication
including non-
prescription medication.
Part C
Part C is the annual physical. This page should be completed and signed by the health care professional
conducting the physical examination. Physicals are required for all events lasting longer than 72 hours. Physicals
expire after the last day of the 12
th
calendar month from the physical exam date (similar to car inspection stickers)
Part D-NH
Part D-NH is unique to Camp Wanocksett. This page provides permission to possess & use epinephrine auto-
injectors and/or asthma inhalers. The Scout's health care professional and the parent/guardian must sign the
bottom of this page. This Is required by NH state regulations; this page is not required for Scouts attending any
camps in Massachusetts.
Part D-MA
Part D-MA is unique to Treasure Valley and HNE's Cub Scout Day Camp Programs. This page includes
authorizations for Scouts to participate in Shooting Sports activities during summer camp as well as be provided
with specific over-the-counter medications. A parent/guardian must sign the bottom of this page. These items are
required by MA state regulations; this page is not required for Scouts attending Camp Wanocksett.
Common Mistakes
Missing parent/guardian signature (Part A)
Missing emergency contact information (Part B)
Incomplete medication information (Part B)
Missing signature for non-prescription
medication (Part B)
Missing medical insurance card (Part B)
Missing complete immunization record (Part B)
Missing physician signature (Part B & C)
Physical exam more than 12 months ago (Part C)
NOTE: NH State regulations require that a copy of your complete immunization record be attached to your medical form. MA
State regulations require written documentation showing immunizations are up to date in accordance with the most current
CDC Immunization Schedules.
Only submit a COPY of your medical form. Keep the original for use at other Scouting activities.
Part A
Part B1
Part
B2
Part C
Participants and parents
(if participant is under 18)
must sign to
acknowledge the
informed consent and
release on this page.
Adults authorized to, or
prohibited from, taking a
participant to/from and
event.
Include insurance
information and attach a
copy of the participant’s
insurance card (front and
back).
List all allergies, and
medications taken.
Even if the participant doesn’t
take prescription medications,
you must check “yes” to
authorize OTC non-prescription
medications.
Parents and physician must sign to
authorize prescription medicants.
No prescription medications? Only
a parent needs to sign for OTC
non-prescription medications.
Attach a complete immunization
record to the medical form (State
Law)
Health Care professional
must complete this page.
Additional pages can be
attached if necessary.
Health Care professional
must sign and date here.
Part A: Informed Consent, Release Agreement, and Authorization
Full name: ___________________________________________
Date of birth: _________________________________________
A
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
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Adults NOT Authorized to Take Youth to and From Events:
Informed Consent, Release Agreement, and Authorization
I understand that participation in Scouting activities involves the risk of personal injury, including
death, due to the physical, mental, and emotional challenges in the activities offered. Information
about those activities may be obtained from the venue, activity coordinators, or your local council.
I also understand that participation in these activities is entirely voluntary and requires participants
to follow instructions and abide by all applicable rules and the standards of conduct.
In case of an emergency involving me or my child, I understand that efforts will be made to
contact the individual listed as the emergency contact person by the medical provider and/or
adult leader. In the event that this person cannot be reached, permission is hereby given to the
medical provider selected by the adult leader in charge to secure proper treatment, including
hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical
providers are authorized to disclose protected health information to the adult in charge, camp
medical staff, camp management, and/or any physician or health-care provider involved in
providing medical care to the participant. Protected Health Information/Condential Health
Information (PHI/CHI) under the Standards for Privacy of Individually Identiable Health Information,
45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination
ndings, test results, and treatment provided for purposes of medical evaluation of the participant,
follow-up and communication with the participant’s parents or guardian, and/or determination of
the participant’s ability to continue in the program activities.
(If applicable) I have carefully considered the risk involved and hereby give my informed consent
for my child to participate in all activities offered in the program. I further authorize the sharing
of the information on this form with any BSA volunteers or professionals who need to know of
medical conditions that may require special consideration in conducting Scouting activities.
With appreciation of the dangers and risks associated with programs and activities, on my
own behalf and/or on behalf of my child, I hereby fully and completely release and waive
any and all claims for personal injury, death, or loss that may arise against the Boy Scouts
of America, the local council, the activity coordinators, and all employees, volunteers,
related parties, or other organizations associated with any program or activity.
I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their
authorized representatives, the right and permission to use and publish the photographs/lm/
videotapes/electronic representations and/or sound recordings made of me or my child at all
Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity
coordinators, and all employees, volunteers, related parties, or other organizations associated
with the activity from any and all liability from such use and publication. I further authorize the
reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said
photographs/lm/videotapes/electronic representations and/or sound recordings without limitation
at the discretion of the BSA, and I specically waive any right to any compensation I may have for
any of the foregoing.
Every person who furnishes any BB device to any minor, without the express or implied permission
of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code
Section 19915[a]) My signature below on this form indicates my permission.
I give permission for my child to use a BB device. (Note: Not all events will include BB devices.)
Checking this box indicates you DO NOT want your child to use a BB device.
List participant restrictions, if any: None
________________________________________________________
Complete this section for youth participants only:
Adults Authorized to Take Youth to and From Events:
You must designate at least one adult. Please include a phone number.
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I am participating at
Philmont Scout Ranch, Philmont Training Center, Northern Tier, Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental risk advisories, including height
and weight requirements and restrictions, and understand that the participant will not be allowed to participate in applicable high-adventure programs if those requirements are not
met. The participant has permission to engage in all high-adventure activities described, except as specically noted by me or the health-care provider. If the participant is under the age of 18, a
parent or guardian’s signature is required.
Participant’s signature: ____________________________________________________________________________________________ Date: ______________________________
Parent/guardian signature for youth: __________________________________________________________________________________ Date: ______________________________
(If participant is under the age of 18)
NOTE: Due to the nature of programs and activities, the Boy Scouts of
America and local councils cannot continually monitor compliance of program
participants or any limitations imposed upon them by parents or medical
providers. However, so that leaders can be as familiar as possible with any
limitations, list any restrictions imposed on a child participant in connection with
programs or activities below.
Part B1: General Information/Health History
Full name: ___________________________________________
Date of birth: _________________________________________
B1
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
In case of emergency, notify the person below:
Name: ______________________________________________________________________________Relationship: ___________________________________________________
Address: _________________________________________________________________ Home phone: _________________________ Other phone: _________________________
Alternate contact name: _________________________________________________________________ Alternate’s phone: ______________________________________________
Age: ____________________________ Gender: __________________________ Height (inches): ___________________________ Weight (lbs.): ____________________________
Address: _________________________________________________________________________________________________________________________________________
City: ___________________________________________State: ____________________________ ZIP code: __________________ Phone: ______________________________
Unit leader: ____________________________________________________________________________ Unit leader’s mobile #: _________________________________________
Council Name/No.: _______________________________________________________________________________________________________Unit No.: ____________________
Health/Accident Insurance Company: ________________________________________________________ Policy No.: ___________________________________________________
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Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance, enter “none” above.
Part B2: General Information/Health History
Full name: ___________________________________________
Date of birth: _________________________________________
B2
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
YES NO Non-prescription medication administration is authorized with these exceptions: ________________________________________________________________
Administration of the above medications is approved for youth by:
_______________________________________________________________________ / _______________________________________________________________________
Parent/guardian signature MD/DO, NP, or PA signature (if your state requires signature)
Please list any additional information about your
medical history:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
DO NOT WRITE IN THIS BOX.
Review for camp or special activity.
Reviewed by: ___________________________________________
Date: _________________________________________________
Further approval required:
Yes No
Reason: _______________________________________________
Approved by: ____________________________________________
Date: _________________________________________________
DO YOU USE AN EPINEPHRINE YES NO
AUTOINJECTOR? Exp. date (if yes) ___________________________
DO YOU USE AN ASTHMA RESCUE YES NO
INHALER? Exp. date (if yes) ___________________________________
Allergies/Medications
Immunization
Are you allergic to or do you have any adverse reaction to any of the following?
Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain
Medication Plants
Food Insect bites/stings
List all medications currently used, including any over-the-counter medications.
Check here if no medications are routinely taken. If additional space is needed, please list on a separate sheet and attach.
Medication Dose Frequency Reason
The following immunizations are recommended. Tetanus immunization is required and must have been received within the last 10
years. If you had the disease, check the disease column and list the date. If immunized, check yes and provide the year received.
Yes No Had Disease Immunization Date(s)
Tetanus
Pertussis
Diphtheria
Measles/mumps/rubella
Polio
Chicken Pox
Hepatitis A
Hepatitis B
Meningitis
Inuenza
Other (i.e., HIB)
Exemption to immunizations (form required)
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Bring enough medications in sufcient quantities and in the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking
any maintenance medication unless instructed to do so by your doctor.
Part C: Pre-Participation Physical
This part must be completed by certied and licensed physicians (MD, DO), nurse practitioners, or physician assistants.
Full name: ___________________________________________
Date of birth: _________________________________________
C
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
Please ll in the following information:
Yes No Explain
Medical restrictions to participate
Height/Weight Restrictions
If you exceed the maximum weight for height as explained in the following chart and your planned high-adventure activity will take you more than 30 minutes away from an emergency vehicle/
accessible roadway, you may not be allowed to participate.
Maximum weight for height:
Height (inches) Max. Weight Height (inches) Max. Weight Height (inches) Max. Weight Height (inches) Max. Weight
60 166 65 195 70 226 75 260
61 172 66 201 71 233 76 267
62 178 67 207 72 239 77 274
63 183 68 214 73 246 78 281
64 189 69 220 74 252 79 and over 295
Examiner’s Certication
I certify that I have reviewed the health history and examined this person and nd no contraindications for
participation in a Scouting experience. This participant (with noted restrictions):
True False Explain
Meets height/weight requirements.
Has no uncontrolled heart disease, lung disease, or hypertension.
Has not had an orthopedic injury, musculoskeletal problems, or orthopedic
surgery in the last six months or possesses a letter of clearance from his or her
orthopedic surgeon or treating physician.
Has no uncontrolled psychiatric disorders.
Has had no seizures in the last year.
Does not have poorly controlled diabetes.
If planning to scuba dive, does not have diabetes, asthma, or seizures.
Examiner’s signature: _______________________________________ Date: _______________
Examiner’s printed name: _________________________________________________________
Address: _______________________________________________________________________
City: ______________________________________State: ______________ ZIP code: _________
Ofce phone: ___________________________________________________
Normal Abnormal Explain Abnormalities
Eyes
Ears/nose/throat
Lungs
Heart
Abdomen
Genitalia/hernia
Musculoskeletal
Neurological
Skin issues
Other
Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain
Medication Plants
Food Insect bites/stings
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Height (inches) Weight (lbs.) BMI Blood Pressure Pulse
/
You are being asked to certify that this individual has no contraindication for participation in a Scouting experience. For individuals who will be attending a high-adventure program,
including one of the national high-adventure bases, please refer to the supplemental information on the following pages or the form provided by your patient. You can also visit
www.scouting.org/health-and-safety/ahmr to view this information online.
Part D-NH: Permission to Possess & Use Epinephrine Auto-Injector and/or Asthma Inhaler
Pursuant to NH RSA 485-A:25-a-g, this form must be completed in its entirety and signed by a parent/guardian AND physician in order for
your child to carry an auto-injector and/or asthma inhaler with him/her while at camp.
Physician’s Section
Camper’s Name:
Diagnosis requiring Epinephrine Auto-injector/Asthma Inhaler:
Are there any other medical conditions?  Yes  No If Yes, please explain:
Name/Dose/route of medication:
Date of Order:
Does the camper need assistance with administration of medication?   Yes  No If Yes, please explain:
Specific recommendations for administration (what symptoms would indicate need for administration of this medication?)
List any special side effects, contraindications and/or adverse reactions to be observed if the medication is administered:
List any adverse reactions that may occur to another child, for whom the above medication is not prescribed, should he or
she receive a dose of the medication:
As the child’s physician, I give permission for this child to possess and use  Epinephrine auto-injector  Asthma Inhaler. This child has the
knowledge and skills to safely possess and use the identified medication in a camp setting
Physician’s Signature:
Date
Physician’s Name (printed):
Physician’s Business Phone: Emergency Phone:
Physician’s Address:
Parent/Guardian’s Section
I hereby give permission for the camper named above to keep the above-named medication in his/her possession while attending a Heart
of New England Council Summer Camp. I will also provide a second auto-injector and/or asthma inhaler that, by law, must be kept at the
health lodge for emergencies.
Parent/Guardian Signature:
Date:
Part D-MA: Supplement Required for all youth participants of all programs at Camp Split Rock and Treasure Valley
Camper’s Name :
DOB :
Shooting Sports - Compliance to State Law : Authorized use of firearms by a minor
The Heart of New England Council adheres to all applicable laws and operates under the governance of BSA National Standards as well as
MA State Health Code. As a part of the BSA program, the council operates several safe shooting sports ranges for Scouts to participate in
BB shooting (Cub Scouts, BSA), rifle shooting & shotgun (Scouts, BSA & Venturing, BSA), and archery (All Programs). In order to meet the
Mass General Laws Chapter 140 section 130 the Council requires parental permission to participate in such activities.
MA General Laws Chapter 140, Section 130 ½ “Lawfully furnishing weapons to minors for hunting, recreation, instruction and participation in
shooting sports” stipulates the following:
“Notwithstanding section 130 or any general or special law to the contrary, it shall be lawful to furnish a weapon to a minor for
hunting, recreation, instruction and participation in shooting sports while under the supervision of a holder of a valid firearm
identification card or license to carry appropriate for the weapon in use; provided, however, that the parent or guardian of the
minor granted consent for such activities.
I hereby AUTHORIZE my child, named above, to
participate in all events during summer camp
including (if age appropriate) use of the shooting
sports program areas (for rifle and shotgun under
supervision of an FID instructor).
I DO NOT AUTHORIZE my child, named above, to
participate in shooting sports activities. However, my
child is authorized to participate in all other events
and activities of the camp.
Over-the-Counter Medications
The following over-the-counter medications will be available through
the health officer if a Scout becomes ill during camp. Please check
the medications your child may be given if needed. Medicine will be
administered per package instructions. Please send your child’s own
supply of over the counter medicine (in the original container) if they
are a normal routine or taken daily.
!
NOTE: Failure to complete this
section or to authorize any OTC
Medication can result in an
uncomfortable experience at camp.
If you have any questions regarding
administration of medications,
please contact camp personnel.
Check all that are authorized:
Acetaminophen (Tylenol)
Pepto Bismol
Bug Spray
Sub Burn Cream (Aloe)
Ibuprofen (Motrin)
Decongestant
After Bite
Calamine Lotion
Benadryl/Antihistamine
Antacid
Eye Drops
Antibiotic Ointment
Anti-Diarrhea
Swimmer’s Ear
Sun Block
Parent/Guardian’s Signature:
Date:
March 2018 Page 1 of 4
Authorization to Administer Medication to a Camper
(completed by parent/guardian)
** Newly required Summer Camp 2018 ***
Per State of Massachusetts Department of Public Health
All medications brought to camp, including over the counter, epinephrine injectors and inhalers must be included on this
authorization. See Advisory regarding the Parent/Guardian Authorization to Administer Medication to a Camper.
https://www.mass.gov/lists/recreational-camps-for-children-community-sanitation
All medications must be in original prescription or retail container. All medication must be given by the health
supervisor/nurse. This form must be filled completely.
If more than 4 medications are being brought to camp, please use additional copies of the Authorization to
Administer Medications to a Camper packet.
Please make sure that if any prescriptions are added or changed for the first day of camp that you have
updated this form to include those changes.
We regret any inconvenience that these new State mandated regulations may have and thank you for ensuring
we are in full compliance with all applicable State regulations.
Camper and Parent/Guardian Information
Camper’s Name:
Pack/Troop/Unit #:
Age:
Food/Drug Allergies:
Diagnosis (at parent/guardian discretion):
Parent/Guardian’s Name:
Home Phone:
Business Phone:
Emergency Telephone:
Licensed Prescriber Information
Name of Licensed Prescriber:
Business Phone:
Emergency Phone:
March 2018 Page 2 of 4
Medication Information 1
Name of Medication:
Dose given at camp:
Route of Administration:
Frequency:
Date Ordered:
Duration of Order:
Quantity Received:
Expiration date of Medication Received:
Special Storage Requirements:
Special Directions (e.g., on empty stomach/with water):
Special Precautions:
Possible Side Effects/Adverse Reactions:
Other medications (at parent/guardian discretion):
Location where medication administration will occur:
Medication Information 2
Name of Medication:
Dose given at camp:
Route of Administration:
Frequency:
Date Ordered:
Duration of Order:
Quantity Received:
Expiration date of Medication Received:
Special Storage Requirements:
Special Directions (e.g., on empty stomach/with water):
Special Precautions:
Possible Side Effects/Adverse Reactions:
Other medications (at parent/guardian discretion):
Location where medication administration will occur:
Medication Information 3
Name of Medication:
Dose given at camp:
Route of Administration:
Frequency:
Date Ordered:
Duration of Order:
Quantity Received:
Expiration date of Medication Received:
Special Storage Requirements:
Special Directions (e.g., on empty stomach/with water):
Special Precautions:
Possible Side Effects/Adverse Reactions:
Other medications (at parent/guardian discretion):
Location where medication administration will occur:
Appropriate TVSR Med Office
Appropriate TVSR Med Office
Appropriate TVSR Med Office
March 2018 Page 3 of 4
Medication Information 4
Name of Medication:
Dose given at camp:
Route of Administration:
Frequency:
Date Ordered:
Duration of Order:
Quantity Received:
Expiration date of Medication Received:
Special Storage Requirements:
Special Directions (e.g., on empty stomach/with water):
Special Precautions:
Possible Side Effects/Adverse Reactions:
Other medications (at parent/guardian discretion):
Location where medication administration will occur:
Authorization Information
I hereby authorize the health care consultant or properly trained health care supervisor at _ Treasure Valley Scout Reservation__ _
(name of camp)
to administer, to my child, ____________________________________ the medication(s) listed above, in accordance with 105 CMR
(name of camper)
430.160(C) and 105 CMR 430.160(D) [see below].
If above listed medication includes epinephrine injection system:
I hereby authorize my child to self-administer , with approval of the health care consultant Yes No Not Applicable
I hereby authorize an employee that has received training in allergy awareness and epinephrine administration to administer
Yes No Not Applicable
If above listed medication includes insulin for diabetic management:
I hereby authorize my child to self-administer , with approval of the health care consultant Yes No Not Applicable
Signature of Parent/Guardian:
Date:
** Health Care Consultant at a recreational camp is a Massachusetts licensed physician, certified nurse practitioner, or a physician assistant
with documented pediatric training. Health Care Supervisor is a staff person of a recreational camp for children who is 18 years old or older;
is responsible for the day to day operation of the health program or component, and is a Massachusetts licensed physician, physician
assistant, certified nurse practitioner, registered nurse, licensed practical nurse, or other person specially trained in first aid.
Appropriate TVSR Med Office
March 2018 Page 4 of 4
105 CMR 430 References
105 CMR 430.160(A): Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the
date of filling, the pharmacy name and address, the filling pharmacist’s initials, the serial number of the prescription, the name of the patient,
the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any,
contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for
campers shall be kept in the original containers containing the original label, which shall include the directions for use. (M.G.L. c. 94C § 21).
105 CMR 430.160(C): Medication shall only be administered by the health care supervisor or by a licensed health care professional authorized
to administer prescription medications. If the health care supervisor is not a licensed health care professional authorized to administer
prescription medications, the administration of medications shall be under the professional oversight of the health care consultant. The health
care consultant shall acknowledge in writing a list of all medications administered at the camp. Medication prescribed for campers brought
from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian.
105 CMR 430.160(D): A written policy for the administration of medications at the camp shall identify the individuals who will administer
medications. This policy shall:
(1) List individuals at the camp authorized by scope of practice (such as licensed nurses) to administer medications; and/or other individuals
qualified as health care supervisors who are properly trained or instructed, and designated to administer oral or topical medications by the
health care consultant.
(2) Require health care supervisors designated to administer prescription medications to be trained or instructed by the health care consultant
to administer oral or topical medications.
(3) Document the circumstances in which a camper, Heath Care Supervisor, or Other Employee may administer epinephrine injections. A
camper prescribed an epinephrine auto-injector for a known allergy or pre-existing medical condition may:
a) Self-administer and carry an epinephrine auto-injector with him or her at all times for the purposes of self-administration if:
1) the camper is capable of self-administration; and
2) the health care consultant and camper’s parent/guardian have given written approval
(b) Receive an epinephrine auto-injection by someone other than the Health Care Consultant or person who may give
injections within their scope of practice if:
1) the health care consultant and camper’s parent/guardian have given written approval; and
2) the health care supervisor or employee has completed a training developed by the camp’s health care consultant in accordance
with the requirements in 105 CMR 430.160.
(4) Document the circumstances in which a camper may self-administer insulin injections. If a diabetic child requires his or her blood sugar be
monitored, or requires insulin injections, and the parent or guardian and the camp health care consultant give written approval, the camper,
who is capable, may be allowed to self-monitor and/or self-inject himself or herself. Blood monitoring activities such as insulin pump calibration,
etc. and self-injection must take place in the presence of the properly trained health care supervisor who may support the child’s process of
self-administration.
105 CMR 430.160(F): The camp shall dispose of any hypodermic needles and syringes or any other medical waste in accordance with 105
CMR 480.000: Minimum Requirements for the Management of Medical or Biological Waste.
105 CMR 430.160(I): When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication
cannot be returned, it shall be disposed of as follows:
(1) Prescription medication shall be properly disposed of in accordance with state and federal laws and such disposal shall be documented in
writing in a medication disposal log.
(2) The medication disposal log shall be maintained for at least three years following the date of the last entry.