BPEEC Medication Administration Form
For prescription & non-prescription medication to be administered at camp
Child Information
Childs Name
*
First Name
Last Name
Childs date of birth
*
-
Month
-
Day
Year
Date
Child's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medication Information
Medication Name, as it appears on the label
*
Dosage to be administered
*
Method of Administration
*
Time to administer
*
Hour Minutes
AM
PM
AM/PM Option
Time to administer if more than once
Hour Minutes
AM
PM
AM/PM Option
Reason for medication
*
Side Effects & Additional information
*
If bringing an EpiPen, it is required by MN First Aid that 2 EpiPens are available.
*
I will send my camper with 2 EpiPens.
My camper does not require EpiPens.
Complete if Medication is Prescribed
Prescriber's Name
First Name
Last Name
Prescriber's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date prescribed by a doctor
-
Month
-
Day
Year
Date
Guardian Information
Guardian Name
*
First Name
Last Name
Guardian Phone Number
*
Please enter a valid phone number.
Guardian Email
*
example@example.com
Guardian Consent
Date that consent given
*
-
Month
-
Day
Year
Date
Guardian Signature
*
Terms and Conditions
Medication must be all medication should be in original named box / bottle and always labelled with the child’s name, DOB, dose and date. (dispensed from the pharmacy). Please supply a measured medicine spoon / syringe. Please give staff all the information required to insure the well-being of the child. At least one dose of the medication has already been administered and my child has not suffered any unwanted reactions. All forms should have clear and specific Reasons, Signs & Symptoms Our day is 24hrs day so 3 times/day means every 8hrs, unless stated by the GP. Staff will log in medication administration on family.
Agreement to terms and conditions
*
I agree to the terms and conditions above
Submit
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