PC24 MEDICATION RELEASE FORM

MEDICATION RELEASE FORM

The Pursuit Camp 2024
Student Name*

First NameLast Name
Parent Name*

In case contact needs to be made.Last Name
Parent Email:*
example@example.com
Parent Phone:*
Please enter a valid phone number.
Medication name:*
Condition being treated:*
Dose: *
mg, ml, units, drops, etc.
Frequency:*
Number of times per day
Time of Day Medication is Given*
How is Medication Administered?*
orally, topically, nasally, etc.
Possible Side Effects or Interactions**
headache, nausea, etc.
I give permission for an appointed Nurse or Nurses at the Pursuit Camp 2024, to administer this medication according to the instructions outlined above. I agree that the one administering or an appointed camp leader 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.
Sign Here (Parent Guardian Name)

First NameLast Name
Should be Empty: