2024 Summer Tri-Wing MDH_4758-B Maryland Medication Administration Authorization Form Upload

MDH_4758-B: Maryland Medication Administration Authorization Form
All minor cadets that need to take daily prescribed medications, including vitamins/homeopathic/herbal medicines and other over-the-counter medication, must submit a completed Maryland Medication Administration Form. Wet signatures are required on this form.
1. Download a form at the link below:
  1. https://health.maryland.gov/phpa/OEHFP/CHS/Shared%20Documents/Youth%20Camps/MMA-B.pdf
2. Complete the form and obtain required WET signatures which includes both Physician and parent/guardian signatures.
3. An electronic copy/scan/photo must be submitted using this online form.
4. A complete hardcopy of the the signed for with original WET signatures must be brought to in-processing.
Name*

First NameLast Name
CAP ID*
Date of Birth*

MonthDayYear
Date
Date Maryland Medication Form Signed*

MonthDayYear
Date
Please upload a photo or scan of the COMPLETED/SIGNED Maryland Administration Authorization Form. Make sure the document can be clearly read and is signed by both the parent and physician. Medication cannot be dispensed if this form is not completed in its entirety and signed.*

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MDH_4758-B: Maryland Medication Administration Authorization Form