AUTHORIZATION FOR ADMINISTRATION OF MEDICATION
***Print this page and have it filled out and signed by your student's physician/provider***
PARENT PROCEDURES FOR MEDICATIONS:
Have this medication consent form properly filled out and signed by a licensed health care provider.
1. Useoneformpermedication;thisincludesbothprescriptionandnonprescription medication including vitamins, homeopathic and herbal medication.
(Example: One tablet every day x 4 days of camp = 4 tablets).
Camper’s name: _______________________________________ Birth date: __________________
Condition(s) being treated: ___________________________________________________________
Name of medication: ________________________________________________________________
Dose: ________________________________ Route: _____________________________________
Time and frequency to be administered during camp: ______________________________________
Start and stop dates for medication: ____________________________________________________
Expected medication side effects, if any: ________________________________________________
For inhalers and epi-pens only: medication may be self-carried and administered (circle one) : Yes No
Prescriber's Name and Title (printed): __________________________________________________
Phone: _________________________________________ Fax: _____________________________
Prescriber’s Signature: _____________________________________________Date:_____________ ✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴✴
PARENT/GUARDIAN REQUEST AND AUTHORIZATION
I request and authorize a camp-designated staff member to administer prescription medication to _____________________ (“Camper”) in accordance with the directions provided by Camper’s licensed health care provider. I understand that I must provide the medication to the camp staff in its original container with the label intact. I agree to hold Gracepoint Church harmless from any damages that may occur to Camper in connection with the camp’s agreement to administer medication in accordance with my request and authorization.
Signature of Parent/Guardian: ______________________________________________
Printed name of Parent/Guardian:_________________________________ Date: ____________ Questions? Contact Nurse Amy at firstname.lastname@example.org and use “GracePoint Camper” as the subject line