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Department of Health & Mental Hygiene (DHMH)

MEDICATION ADMINISTRATION

Center for Healthy Homes and Community Services (CHHCS)

6 St. Paul Street, Suite 1301

AUTHORIZATION FORM

Baltimore, Maryland 21202-1608

(410) 767-8417 FAX (410) 333-8926

Toll Free 1-877-4MD-DHMH ext. 8417

I. CAMP OPERATOR

This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the

camper to self administer medication. A new medication administration form must be completed at the beginning of each camp season,

for each medication, and each time there is a change in dosage or time of administration of a medication.

Prescription medication must be in a container labeled by the pharmacist or prescriber.

Nonprescription medication must be in the original container with the instructions for use. Nonprescription medication includes

vitamins, homeopathic, and herbal medicines.

An adult must bring the medication to the camp and give the medication to an adult staff member.

II. CAMP INFORMATION

YOUTH CAMP NAME

Butler Camp

PHYSICAL ADDRESS

15951 Germantown Road

20874

CITY

STATE

ZIPCODE

Darnestown

Maryland

III. PRESCRIBER’S AUTHORIZATION

CHILD’S NAME

DATE OF BIRTH

CONDITION FOR WHICH MEDICATION IS BEING ADMINISTERED:

EMERGENCY MEDICATION

[ ] YES

[ ] NO

MEDICATION NAME

DOSE

ROUTE

TIME/FREQUENCY OF ADMINISTRATION

IF PRN, FREQUENCY

IF PRN, FOR WHAT SYMPTOMS

KNOWN SIDE EFFECTS SPECIFIC TO CHILD

MEDICATION SHALL BE ADMINISTERED

FROM

(NOT TO EXCEED 1 YEAR)

PRESCRIBER’S NAME/TITLE

This space may be used for the Prescriber’s Address Stamp

TELEPHONE

FAX

ADDRESS

CITY

STATE

ZIPCODE

PRESCRIBER’S SIGNATURE (Parent cannot sign here)

DATE

(ORIGINAL SIGNATURE OR SIGNATURE STAMP ONLY)

IV. PARENT/GUARDIAN AUTHORIZATION

I request authorized youth camp operator/staff to administer the medication as prescribed by the above prescriber. I certify that I have legal

authority to consent to medical treatment for the child named above, including the administration of medication at the facility. I understand that at

the end of the authorized period, an adult must pick up the medication, otherwise it will be discarded. I authorize camp personnel to communicate

with the prescriber as allowed by HIPAA. I confirm that, if the medication above is a prescription medication, the child has at some point taken the

medication prior to attending camp.

PARENT/GUARDIAN SIGNATURE

DATE

HOME PHONE #

CELL PHONE #

WORK PHONE #

V. AUTHORIZATION FOR SELF ADMINISTRATION AND SELF CARRY

I consent that the child named above is able to self administer the medication listed. I authorize self administration of the above listed medication for

the child named above under the supervision of an authorized youth camp operator/staff member. The child named above may self carry emergency

medication if indicated below.

PRESCRIBER’S SIGNATURE

SELF CARRY EMERGENCY MEDICATION (Check One)

DATE

[ ] YES

[ ] NO

[ ] Not emergency medication

PARENT/GUARDIAN’S SIGNATURE

SELF CARRY EMERGENCY MEDICATION (Check One)

DATE

[ ] YES

[ ] NO

[ ] Not emergency medication

DHMH #

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Medication Administration Authorization Form - Department Of Health And Mental Hygiene

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