SEA Medication Authorization, Health & Immunizations Record

SEA Medication Authorization, Health & Immunizations Record

Use this form to submit the completed "Authorization for the Administration of Medication by SEA Program Personnel" and the "Physical Examination and Immunizations Record" for SEA events where SEA staff or volunteers will be the primary caretakers of participants.
Please download and have a physician or nurse practitioner complete

(1) Physical Examination and Immunizations Record &

(2) Authorization for the Administration of Medication by SEA Program Personnel
Name of attendee*

First NameLast Name
Member Program Site*
Select "SEA - NYC" if you are working for SEA at an event or you are not associated with an SEA member organization.
Authorization for the Administration of Medication by SEA Program PersonnelPhysical Examination and Immunizations RecordBoth above forms
Document upload*

Both the "Authorization for the Administration of Medication by SEA Program Personnel" and "Physical Examination and Immunizations Record" must be completed and signed by a physician or nurse practitioner. The immunization list must come from a doctor's office. The physical examination must have been completed within the last 24 months and must detail all medications, allergies and/or dietary restrictions, past medical treatments, and any physical, mental, or psychological conditions requiring medication, treatment, or special restrictions or considerations while at the SEA event.
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