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.