Request to Administer Medication on Camp (Nationwide Form)

Request to Administer Medication on Camp (Nationwide Form)

ABN: 55 637 079 620
Participant Name*
Please provide a list of all medications required to be administered whilst on camp. It is the parent/guardian’s responsibility to;

1. Provide medication/s in original pharmacy box/container including the pharmacy label with the participant’s name, dosage and time/s to be taken.

2. Provide across the counter medications eg antihistamine – ensure medication is not out of date and give a short explanation for when/why the medication is required.

3. Include any relevant information/instructions regarding medications. I hereby give permission for the camp leader(s) to administer medications as detailed

Medication Administration Details

	Name of medication	Dosage (eg 5mg/5ml)	Route (eg oral,eye drop,topical)	Time/s to be given on camp	Reasons for administration, instructions. Eg with food, before bed etc

Anything else you would like us to know:
Comments
Parent/Guardian Name*
Parent/Guardian Email*
example@example.com
Date*

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Date
Signature*

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