2025 Medication Authorization Form

MEDICATION AUTHORIZATION FORM
Mountain Harmony Camp

Region 12, Sweet Adelines International

Camp Dates: Fri., Nov. 21, 2025 - Sun., Nov. 23, 2025
Childs Name*
Date of Birth*

MonthDayYear
Date
Weight (for dosage accuracy)
Emergency Medications:

Please sign the appropriate section if your child must carry their own Inhaler or EpiPen
ASTHMA / INHALER

As the parent/guardian of this child, I acknowledge that my child is responsible for, and competent in the appropriate use of, her prescribed asthma inhaler. I authorize my child to possess/carry her own prescribed asthma inhaler while at camp. I have provided a second inhaler to the Camp Nurse in case of loss or other emergency.
ASTHMA / INHALER PERMISSION Parent Initials

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EpiPen / Twinject / Auto Injector

As the parent/guardian of this child, I acknowledge that my child is responsible for, and competent in the appropriate use of, her prescribed Epinephrine Auto-Injector. I authorize my child to possess/carry her own prescribed injector while at camp. I understand the Camp Nurse, or other designated adult, will immediately request assistance from an emergency medical service provider if this medication is administered. I have provided a backup dose of this medication to the Camp Nurse in case of loss or other emergency.
EPIPEN / TWINJECT/ AUTO INJECTOR Parent Initial

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List all medications below

Use additional information box at bottom of section to add more
MEDICATION #1 Medication Name
Treatment of:
Mg / Type Ex: 100 mg Tablet
Dosage & Time given
MEDICATION #2 Medication Name
Treatment of:
Mg / Type Ex: 100mg Tablet
Dosage & Time Given
MEDICATION #3 Medication Name
Treatment of:
Mg & Type Ex: 100 mg Tablet
Dosage & Time given
MEDICATION #4 Medication Name
Treatment of:
Mg & Type Ex: 100 mg Tablet
Dosage & Time Given
Additional Medical Information you'd like to include:
Release of Claims

Parent must sign this section
As the parent/guardian of the above-named child I have read and complied with the following Mountain Harmony Camp rules for administering medication while at camp and herby give my permission for administration.
- The medication must be in its original container, with a legible label from the pharmacy, indicating the child's name, date, name of medication, expiration date, dosage, time and number of days medication is to be given, the doctor/nurse practitioners name, pharmacy name and telephone number.
- Over the counter medications must also be in their original containers and labeled with child's name
- Any medication samples must be accompanied by a doctor's written prescription.
- Medications are to be given only to the child indicated on the label (twins / siblings cannot share)
- Label constitutes the physicians/nurse practitioner's order
- As the parent/guardian of the above-named child, I give permission for the designated Camp Nurse to administer the prescribed, or non-prescribed, medication(s) listed below to my child. The undersigned agrees not to file or make any claim for negligence in connection with the administration or non-administration of this medicine(s) and further agrees to hold Sweet Adelines International, Pacific Shores Region 12, their representatives and the Camp Nurse harmless from any liability incurred as a result of the administration or non-administration of any medicines listed.
Name of Parent / Guardian please print*
Signature of Parent / Guardian*

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Date*

MonthDayYear
Date
Primary Emergency Phone*
Secondary Emergency Phone
Should be Empty:

MEDICATION AUTHORIZATION FORM

Emergency Medications:

List all medications below

Release of Claims