Medication Administration Record
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1Medication Administration Record (MAR) for Mountain Meadows Bible Camp
Name
Date of Birth
Date of Camp
Counselor
______________________________
_______________
__________________
_______________________
Age
M / F Allergies
Group Name
Parent’s Sig.
_____
______________________________
__________________
______________________________
Medication Administration Guidelines:
1. Please place medications in a Ziplock bag clearly labeled with full name and date of birth written in permanent marker on the outside.
2. Medications must be in original container with doctor’s directions if it is a prescription (no pills in bags or daily dispensers).
3. Please send an inhaler if your child has asthma. Please send an Epi-pen if your child has a history of severe allergic reaction.
4. Primary dispensing times for medications will be at meal times unless otherwise directed by a physician. Thank you!
5. Fill out shaded column only; daily columns for administration use only.
Medications
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Name_______________________ Dose____________
Route____________ Freq _______________________
Reason_______________________________________
Name_______________________ Dose____________
Route____________ Freq _______________________
Reason_______________________________________
Name_______________________ Dose____________
Route____________ Freq _______________________
Reason_______________________________________
Name_______________________ Dose____________
Route____________ Freq _______________________
Reason_______________________________________
Name_______________________ Dose____________
Route____________ Freq _______________________
Reason_______________________________________
(___) ____________________ (___)______________________ (___)______________________
Administrator Signature
Form updated May, 2010 all previous forms obsolete. Form available at
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Parent category: Medical