Camp Oasis Medication Authorization Form printable pdf download

CAMP OASIS M edication Authorization Form

This form is required if your child will need any medication, prescription or non-prescription, while attending camp.

To be filled out completely by parents or physician, and signed by a physician. PLEASE PRINT LEGIBLY!

Camper’s Name: ______________________________________________ Home Phone: ___________________________

Camper’s Address: ____________________________________________________________________________________

Street

City

State

Zip

MEDICATION POLICY: If possible, arrange time of dosage so that medication(s) will not have to be given while the child is at camp.

Prescription medication must be in its original bottle with the doctor’s instructions. Non-prescription medication must be in its original

packaging, and will be given according to package directions unless accompanied by a note from a physician indicating otherwise.

The following m edication(s) must be taken d uring camp ho urs:

Medication

Dosage

Hour Given

Adm inistration instruc tions (give with water, m ilk, food, etc.):

____________________________________________________________________________________________________

List any reaso ns for not giving m edication at th e prescribed time (vom iting, fever, drow siness, etc.):

____________________________________________________________________________________________________

This medication is to be administered only until: _________ _________ _________ ___ (Date)

The following medication(s) are administered only at home:

Medication

Dosage

Hour Given

For all med ications, includ ing those give n at hom e, list all side effects wh ich should be observe d by cam p personne l:

____________________________________________________________________________________________________

PARENT AUTHORIZATION: Before Camp Oasis staff can administer any medication to your child, you are required to sign this

authorization form indicating your desire to have the medication(s) administered, as well as your agreement to relieve Camp Oasis, its

agents, employees, or representative of any responsibility for ill effects resulting from the administering of said medication as set forth

within.

Please choose an option below:

My child is at least 8 years old (by June 22, 2015), and has my permission to administer his/her own medication under the supervision of

Camp Oasis staff.

My child is under age 8, and has my permission to administer his/her own medication under the supervision of Camp Oasis staff.

We therefore authorize and request that CAMP OASIS administer the medication prescribed by our physician, and in doing so, relieve CAMP

OASIS, its agents, employees or representatives of any responsibility for ill effects resulting from the administering of said prescription or non-

prescription medication.

Signature of Parent:

___________________________________________________________________________________________________

Witness: ___________________________________________________________________ Date: __________________

This form must be kept current. Whenever there is a change in medication, parents must have a new form signed by the

physician. This form must be signed by a physician to be valid.

Physician’s Signature: ___________________________________________ Date: _____________________

Address: _______________________________________________________ Phone Number: _____________________

Camp Oasis Medication Authorization Form

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