CARAVEL ACADEMY PRESCRIPTION MEDICATION FORM

CARAVEL ACADEMY PRESCRIPTION MEDICATION FORM

For Camp Prescription Medication Administration
This form should be completed when a student requires prescription medication during the hours of band camp. Examples of these medications would include the following: antibiotics for infection; Adderall/Ritalin for AD/ADHD; Insulin; Albuterol solution for nebulizing; or inhaler.

PLEASE NOTE: All medications must be delivered to the Band Camp Administration upon arrival at camp. It must be in the ORIGINAL CONTAINER with the pharmacy label intact and current. It must be in a CLEAR Ziploc-type baggie with your child’s name CLEARLY written on the front.
Student Name*

First NameLast Name
Student Grade*

7th8th9th10th11th12th
Allergies:
Name of Medication:
Prescribing doctor's name of this medication:
Doctor's Phone #:
Please enter a valid phone number.
Student being treated for:
Time to be given:
Dose to be given:
Special Instructions:
Parent / Guardian Name*

First NameLast Name
Parent / Guardian phone #*
Please enter a valid phone number.
By signing below, I accept full responsibility for notifying the Band Camp Administration of any changes or difficulties that may develop while dispensing this medication. I have provided the above named prescription medication in the original container with the pharmacy label intact. I understand that failure to provide the above may delay administration of the medication until clarification is obtained. *

Clear
Should be Empty: