Because the   First Name   Last Name   requires medication during camp hours, I request that the medical staff at the Summer Manufacturing Institute be permitted to give this medication as directed below. I will provide the medication in an original pharmaceutically filled container whose label will clearly indicate the physician’s instructions for administration and physician’s name.   I understand that the Summer Manufacturing Institute will not administer medications not listed on this form or in their original pharmaceutically filled container.     Signature   

Medication Name(s):      
Dosage:      
Time(s) of Day to be Given:      
Possible Side Effects:      
Who will administer your prescribed medication?:    Please Select I authorize and recommend self-medication by my child for the prescribed listed medication. I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending prescribed
Epi-Pen (Epinephrine):    Please Select I authorize and recommend self-medication by my child for the prescribed listed medication. I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending prescribed