Capf 163 - Cap Members
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1PERMISSION FOR PROVISION OF MINOR CADET OVER-THE-COUNTER MEDICATION
This form may not be usable in some states due to statutes concerning who can administer
medications and administration conditions. Wings with such restrictions will publish
appropriate additional guidance in a supplement to CAPR 160-1.
Name (Last, First, Middle)
Grade
CAPID
Charter Number
Over-The Counter/Non-Prescription Medications
The following over-the counter medications may be administered according to package
directions by CAP senior members. Cross out any medications not approved.
Acetaminophen (Tylenol) for fever or pain
Visine eye drops for dry, irritated eye relief
Ibuprofen (Advil, Motrin) for fever or pain
Op-Con A eye drops for allergic conjunctivitis
Bacitracin or Neosporin antibiotic ointment to
Benadryl liquid/tabs for allergic reactions
prevent infection
Claritin antihistamine for seasonal allergies
Hydrocortisone anti-inflammatory rash cream
Robitussin products for relief of cough and
Calamine/Caladryl for poison ivy itch relief
cold symptoms
Antifungal creams and sprays for treatment of
Delsym to suppress cough
fungal rashes
Tums or Maalox for relief of stomach upset
Allergies
My child/ward has the following allergies or reactions to over-the-counter medications (list type
of reaction):
Consent For Minor Cadet To Receive Over-The-Counter Medications
My signature below evidences my consent for CAP senior members to provide over-the-
counter non-prescription medications (such as those listed above) to my child/ward if indicated
in the reasonable judgment of such senior members. I understand that I will be informed if any
such medications are administered.
Date
Signature of Parent/Guardian
CAPF 163, JUN 13
OPR/ROUTING: HS
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