Authorization for the Administration of Medication

Parents/guardians requesting medication administration to their child while at camp shall provide the program with appropriate written authorization(s) and the medication before any medications are administered. Medications must be in the original container and labeled with the child’s name, name of medication, directions for medication’s administration, and date of the prescription. All unused medication shall be destroyed if not picked up within one week following the camper’s departure at the end of camp.

Authorized Prescriber’s Order (Physician, Dentist, Physician Assistant, Advanced Practice Registered Nurse):

Name of Child ____________________________________________________________________

Date of Birth ____/_____/_____ Today’s Date ____/____/____

Medication Name_________________________________________

Controlled Drug □ Yes □ No

Dosage ____________________ Method _______________

Time of Administration _____________

Specific Instructions for Medication Administration
________________________________________________________________________________

Medication Administration: Start Date _____/_____/_____
Stop Date: _____/_____/_____

Is This Medication to be self-administered by the child? □ Yes □ No

Relevant Side Effects of Medication
_______________________________________________________________________________

Plan of Management for Side Effects
_______________________________________________________________________________

Known Food or Drug Allergies? □ Yes □ No    Reactions To? □ Yes □ No     Interactions To? □ Yes □ No

If “yes” to any of the Above, Please Explain:
_______________________________________________________________________________

Prescriber’s Name
_______________________________________________________________________________
Phone Number
(______) _______________

Prescriber’s Address
_______________________________________________________________________________

Prescriber’s Signature
_______________________________________________________________________________

Parent/Guardian Authorization:
□ I Request that medication be administered to my child as described and directed above
□ I request that medication be self-administered to my child as described and directed above

Name of Camp_____________________________ Today’s Date ______/______/______

Child’s Name
_______________________________________________________________________________

Address
_______________________________________________________________________________

Name of Parent/Guardian Authorizing Administration of Medication
_______________________________________________________________________________

Relationship to Child: □ Mother □ Father □ Guardian/ Other (explain) __________________________

Name of Camp Personnel Receiving Written Authorization and Medication
_______________________________________________________________________________

Title/Position _______________Signature (in ink) ______________________________