Item: __________________________________
Item: __________________________________
Item: __________________________________
Frequency: ______________________
Frequency: ______________________
Frequency: ______________________
Notes:____________________________________________________________________________________________
_________________________________________________________________________________________________
If your child needs a prescription medication administered during the camp day or will be bringing a medication with
them to camp each day (EpiPen, inhaler, etc.) please fill out this portion of the form.
N
ame of Medication: _______________________________________________
Prescription Number: _________________________________
Time medication is to be administered: ________________
(Prescription medications will not be given on an “as needed” basis; specific times must be provided.)
Amount/dose of medication to be given: ________________________________
Dates medication is to be administered: ________________________________
Who is allowed to administer medications (check all that apply):
Camp Director Camp Counselor Administration Staff Member
Parent/Guardian Signature: ________________________________ Date: _________________
Camp Director Signature: __________________________________ Date: __________________
Camp Elachee Medication Authorization Form
This form must be completed in its entirety before Camp Elachee staff members can dispense any medicat
ions.
Please list any over the counter medications (like chewable Benadryl, Neosporin cream) and/or other substances (sunscreen,
bugspray, anti-itch, etc.) that may be administered on an as needed basis for your child during the course of the camp week.
Child’s Name: __________________________________________
Age: ____________
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