Bcba Registration For Camp Page 7
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13Medicine Dispensing Form
TDH Laws require that, all medication, prescription or non-prescription drugs will be held at the camp
first aid station and administered by camp approved, medical personnel, who are on duty 24 hours a
day.
If you need to send medication to camp, please put it along with this completed form in a zip-lock bag.
! ALL MEDICATIONS MUST BE IN ITS ORIGINAL CONTAINERS FROM THE
PHARMACY. NO BLANK PILL BOTTLES OR DAILY MEDICATION BOXES.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
PUT THIS FORM IN THE ZIP LOCK BAG
ALONG WITH THE MEDICINE
This medication belongs to:________________________________________________
Camper’s Church:_______________________________________________________
Councilor/Sponsor Name:_________________________________________________
Parent Name:___________________________________________________________
Day Phone:_______________________ Night Phone:_________________________
Parent (please circle) will / will not allow over the counter medicines to be dispensed to their
camper exceptions are:_____________________________________________
(Example: cough drop, antacid, band aid, acetaminophen, ibuprofen, etc.)
Medication Name
Dosage
Dosage Time
Special Instructions
AM/Noon/PM/Bedtime
If medication is only “as needed” tell us the circumstances in which to administer the
medication:____________________________________________________________
Signature:_____________________________________________________________
Page 4 of 4
Updated December 2015 djb
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