Medication Control Permission Form - Weekend Trips
Download a blank fillable Medication Control Permission Form - Weekend Trips in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medication Control Permission Form - Weekend Trips with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1BOY SCOUT TROOP 1539 – PLYMOUTH-CANTON, MI
Medication Control Permission Form - Weekend Trips
Camper _________________________________________________________________________________________
Campout Location _______________________________________________
Weekend Date ___________________
I. MEDICATION REQUIRED
Name of Medication ________________________________________________________________________________
Reason for Medication ______________________________________________________________________________
Possible common reaction to medication ________________________________________________________________
Dosage __________________________________________________________________________________________
Time of Administration ______________________________________________________________________________
Comments regarding medication ______________________________________________________________________
This form has been designed to meet both the requirements of the State of Michigan as well as the Boy Scouts of
America. It should offer benefits to the Scout in assuring the proper medication at the proper time, and benefit the leader
in knowing exactly what the parents is requesting the leader to do, and provide a record that the request was carried out.
NOTE: All prescribed medication must be kept in the original container bearing the physician’s name, direction for use,
and the patient’s name.
II. PRESCRIBING PHYSICIAN
Name ___________________________________________________________ Phone _________________________
Address ____________________________________________ City _______________________ Zip _____________
III. PARENT PERMISSION
(RECOMMENDED BY B.S.A.) I want my Scout to be responsible for keeping and administering his own medication
and I have instructed him to keep all medications in a safe place and not share his medication with anyone else.
---- OR ----
I hereby request that my child be administered his prescribed medication at camp by the approved troop leaders
listed below. I understand that the medication at camp will be administered exactly as per the directions as prescribed by
the above physician.
Authorized to administer medication
Steeve Hives (Scoutmaster), Jill Hives (Health Advisor) or designated Adult.
Signed _________________________________________________________________
Parent or Legal Guardian
Medication log for administering (to be filled out by Health Advisor)
All medication must be kept in a safe location.
Friday
Saturday
Saturday
Saturday
Saturday
Sunday
Bedtime
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Admin Initials
__________
__________
__________
__________
__________
__________
Troop 1530 – Permission Slip
3 of 3
Revised 1/22/2013
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business