Camper Medical Administration Form

Camper Medication Administration Form
Camper Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Session 1Session 2Session 3Session 4Session 5Session 6Session 7Session 8Session 9

Must Be Completed for Campers Bringing Medication to Camp
Medication Name*
PrescriptionNon Prescription
Doseage
What time does it need to be administered?*
Reason medication is being administered*
Relevant side effects and anything you want to add*

If you do not have any more medications to list, please scroll down and click on the next page
Medication Name
PrescriptionNon Prescription
Dosage
What time does it need to be administered?
Reason medication is being administered
Relevant side effects and anything you want to add
Medication Name
PrescriptionNon Prescription
Dosage
What time does it need to be administered?
Reason medication is being administered
Relevant side effects

Parent/Guardian Information
Name*

First NameLast Name
Phone Number 1*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Signature*
Date*

MonthDayYear
Date
Should be Empty: