Medication Administration Record Form printable pdf download

Medication Administration Record Form

M ed i cat ion Ad mi ni str a tion R e cord



ALL MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER WITH PHYSICIAN

DIRECTIONS. OTC MEDICATIONS MUST BE IN ORIGINAL MANUFACTURERS PACKAGING.

MEDICATIONS BROUGHT IN ANY OTHER FORM WILL NOT BE ADMINISTERED.

 Please place medication bottles in Ziplock bag clearly labeled with child’s first and last name.

 Primary dispensing times for medications will be at each meal unless otherwise noted by a physician.

 Medications must be turned in to nurse upon arrival at camp. NO medications (prescribed or OTC) or

vitamins are allowed to be kept in the cabins.

 Please circle at which meal your child takes his/her medication.

 Fill out shaded column only; daily columns for administration use only.

Camper Name:_________________________________ DOB:_____________ M/F ____

Parent/Guardian Name: _________________________ Phone Number _____________

Medication Allergies:________________________________________________________

Parent/Guardian Signature____________________________ Date: _________________

Mon

Tues

Wed

Thur

Fri

Sat

Sun

Medication Name

And Times Taken

Supper

Breakfast

Bedtime

Lunch

Supper

Breakfast

Bedtime

Lunch

Supper

Breakfast

Bedtime

Lunch

Supper

Breakfast

Bedtime

Lunch

Supper

Breakfast

Bedtime

Lunch

Medication Administration Record Form

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