Authorization To Administer Medication To A Camper printable pdf download

Authorization To Administer Medication To A Camper

AUTHORIZATION TO ADMINISTER MEDICATION TO A CAMPER

(To be completed by parent/guardian)

Name of Camper: ________________________

Age: ______

Parent/Guardian Name: ______________________

Food/Drug Allergies: ____________________________________

Home Telephone: ___________________________

Diagnosis (at parents discretion): __________________________

Business Telephone: ________________________

Emergency Telephone: _______________________

Name of Licensed Prescriber: _______________________

Business Telephone: _________________________

Emergency Telephone: _______________________

Name of Medication:

Dose given at camp: _________ Route of Administration:

Frequency:

_______ Date Ordered:

Duration of Order: __________________

Quantity Received:

Expiration date of Medications Received:

Special Storage Requirements:

Specific Directions (e.g., on empty stomach/with water):

Specific Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parents’ discretion):

Location where medication administration will occur:

(Over)

Authorization To Administer Medication To A Camper