Base 5/6 Camp Medical Release

Base 5/6 Camp Medical Release
Student's Name*

First NameLast Name
Medication Name*
Condition Being Treated*
Dose*
Frequency*
Time of Day Medication is Given*
How is medication being administered?*
Possible Side Effects of Medication*
I give permission for Mark Schamel, a New Song Nashville volunteer and registered Nurse, to administer this medication according to the instructions outlined above. I agree that Mark Schamel and/or New Song Nashville will not be held liable for any illness resulting from the administration of this medication and will not be held responsible for the reimbursement of any medical expenses resulting from such action.
Parent/Guardian Signature*

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Should be Empty: