Authorization To Administer Medication To A Camper (Page 2 of 2) in pdf

Authorization To Administer Medication To A Camper Page 2

Authorization to Administer Medication to a Camper (2)

I hereby authorize ___________________

___ to administer, to my child, _________________________ _the medication(s)

(NAME OF CAMP)

(NAME OF CHIILD)

listed above, in accordance with 105 CMR 430.160.

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.

105 CMR 430.160(C)

Medication shall only be administered by the health supervisor* or by a licensed health care professional authorized to administer

prescription medications. The health care consultant shall acknowledge in writing the list of medications administered at the camp. If the

health 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. 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)

When no longer needed, medications shall be returned to a parent of guardian whenever possible. If the medication cannot be

returned, it shall be destroyed.

*Health Supervisor – A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross First Aid (or its

equivalent) and CPR, has been trained in the administration of medications and is under the professional oversight of a licensed health care professional

authorized to administer prescription medications.

Parent/Guardian Signature: __________________________________________

Date: _______________________