Permission To Administer Medication

Camper Name *

First

Last

Medication *

Please note: A new form should be used for each medication, whether prescription or non-prescription. Medication must be in original container with the child’s name visible and clearly written on packaging. Please place all medications in a zip lock bag to help secure medicines store dispensing record, and aid person administering medication.

Prescription # or Brand

Medication type *

Prescription
Over the counter

Dosage *

1 teaspoon
2 teaspoon
Other

Frequency *

First dosage to be administered at Camp *

Please include anticipated date and time

Prescribing Physician

Prescribing Physican telephone

Special Instructions

Parent/Guardian Authorization *

First

Last

I hereby authorize Camp Deer Lake to administer listed medication to my child according to the instructions on the medication label.

Record of Dispensation

To be completed by person administering medication.

Permission To Administer Medication

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