Medication Administration Consent Form - Beaver Summer Camp
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1Medication Administration
Consent Form
Complete ONLY if your child requires prescription medications to be administered at camp.
Child’s Name_______________________________________________ Date of Birth_________________
Camp/ Group _______________________________________________Sessions:____________________
Food or Drug Allergies___________________________________________________________________
Parent/Guardian printed name____________________________________________________________
Home Phone (
)___________________
Work Phone (______)_______________________
Cell Phone _____________________________________________________________________
Parent/Guardian printed name____________________________________________________________
Home Phone (
)___________________
Work Phone (______)_______________________
Cell Phone _____________________________________________________________________
I consent to have the camp nurse administer the following medication(s):
Medication Name
Dosage
Time Given
Prescribing Physician
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
My child is getting this medication to treat ___________________________________________________
______________________________________________________________________________________
I do_____ do not _______ give permission for my son/daughter to self-administer his/her INHALER at
camp if the nurse feels it is safe and appropriate.
I do _____ do not_______ give permission to the nurse to share information relevant to the prescribed
medication administration as she determines appropriate for my child’s health and safety.
Parent/Guardian signature ________________________________________ Date _________________
105 CMR.160 (A)
Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the date filling, 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.
105CMR 430.160 (C)
Medication shall only be administered by the health supervisor* or by licensed health care professional authorized to administer prescription medication.
The health care consultant shall acknowledge in writing the list of medications administered at the camp. If the health supervisor is not a licensed heath
care professional authorized to administer prescriptions medications the administration of medication shall be under the professional oversight of the
health care consultant. Medication prescriptions for campers brought from home shall only be administered if it is from the original container, and there
is a 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 healthcare professional
authorized to administer prescription medications.
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