Medication Administration Form

LEGACY CHRISTIAN ACADEMY
Camp Shamineau Medication Administration Form

Mrs. Heilman will be in charge of administering medications to the students. If your child will need medication while at Camp Shamineau (prescription or over-the-counter), please complete this form and return it to the Front Office by Monday, December 8th. If your child has medication in the Legacy Christian Academy Health Office that you would like to be sent, please indicate so on this form.

On the morning of the trip, Tuesday, January 6th, Mrs. Heilman will be available for questions or special directions for students starting at 7:20 a.m. in the church side lobby (door 1).

As a reminder, students are NOT allowed to carry medications (including over the counter) of any kind in their personal belongings. If you will be sending more than one medication, please fill out all areas for each medication.

Thank you, Talisha Heilman R.N - School Nurse, healthoffice@lcamn.org
** LEGACY WILL NOT ADMINISTER MEDICATIONS ON THE MORNING OF THE TRIP
If your child requires morning medication, please do this prior to drop off.
Name

First NameLast Name
Camp Shamineau Medication Authorization: Please list all prescription medications your child will be taking at Camp Shamineau - Include inhalers, nebulizer, Ritalin, etc.
Medication #1 Name
Amount/dosage given
Reason given
Administer at breakfast
Administer at lunch
Administer at dinner
Administer before bed
Administer as needed
Name of physician prescribing medication
Physician phone
Format: (000) 000-0000.
Medication #2 Name
Amount/dosage given
Reason given
Administer at breakfast
Administer at Lunch
Administer at dinner
Administer before bed
Administer as needed
Name of physician prescribing medication
Physician phone
Format: (000) 000-0000.
Medication #3 Name
Amount/dosage given
Reason given
Administer at breakfast
Administer at lunch
Administer at dinner
Administer before bed
Administer as needed
Name of physician prescribing medication
Physician phone
**All medications need to be in their original container, current (not expired) and with your student's name on it. (Your pharmacy will provide an empty bottle upon request**
Should be Empty:

LEGACY CHRISTIAN ACADEMY

** LEGACY WILL NOT ADMINISTER MEDICATIONS ON THE MORNING OF THE TRIP