Medication Authorization Form - Camp Ramah Wisconsin

Please confirm that PackMyRX cannot fulfill your child's medications before completing this form. Click here to visit PackMyRX to register any of your child's medications that are not on the exception list.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Camper Name*

First NameLast Name
Camper Eidah (Age Division)*
Number of medications*
Name of Medication #1*
Medication #1 Dosage*
Medication #1 Frequency of Administration*

Once a DayTwice a DayAs NeededOther
Medication #1 Time of Day to Be Administered*

BreakfastLunchDinnerBedtime
Medication #1 Administration Type*

PillGummyLiquidPowderOther
Medication #1 Length of Time to Be Administered*
Will the camper take this medication for the whole summer, one week, etc?
How will you be sending medication #1 to camp?*

In the mailWith my camper
Medication #1 Special Instructions
Name of Medication #2*
Medication #2 Dosage*
Medication #2 Frequency of Administration*

Once a DayTwice a DayAs NeededOther
Medication #2 Time of Day to Be Administered*

BreakfastLunchDinnerBedtime
Medication #2 Administration Type*

PillGummyLiquidPowderOther
Medication #2 Length of Time to Be Administered*
Will the camper take this medication for the whole summer, one week, etc?
How will you be sending medication #2 to camp?*

In the mailWith my camper
Medication #2 Special Instructions
Name of Medication #3*
Medication #3 Dosage*
Medication #3 Frequency of Administration*

Once a DayTwice a DayAs NeededOther
Medication #3 Time of Day to Be Administered*

BreakfastLunchDinnerBedtime
Medication #3 Administration Type*

PillGummyLiquidPowderOther
Medication #3 Length of Time to Be Administered*
Will the camper take this medication for the whole summer, one week, etc?
How will you be sending medication #3 to camp?*

In the mailWith my camper
Medication #3 Special Instructions
Name of Medication #4*
Medication #4 Dosage*
Medication #4 Frequency of Administration*

Once a DayTwice a DayAs NeededOther
Medication #4 Time of Day to Be Administered*

BreakfastLunchDinnerBedtime
Medication #4 Administration Type*

PillGummyLiquidPowderOther
Medication #4 Length of Time to Be Administered*
Will the camper take this medication for the whole summer, one week, etc?
How will you be sending medication #4 to camp?*

In the mailWith my camper
Medication #4 Special Instructions
Name of Medication #5*
Medication #5 Dosage*
Medication #5 Frequency of Administration*

Once a DayTwice a DayAs NeededOther
Medication #5 Time of Day to Be Administered*

BreakfastLunchDinnerBedtime
Medication #5 Administration Type*

PillGummyLiquidPowderOther
Medication #5 Length of Time to Be Administered*
Will the camper take this medication for the whole summer, one week, etc?
How will you be sending medication #5 to camp?*

In the mailWith my camper
Medication #5 Special Instructions
Name of Medication #6*
Medication #6 Dosage*
Medication #6 Frequency of Administration*

Once a DayTwice a DayAs NeededOther
Medication # 6 Time of Day to Be Administered*

BreakfastLunchDinnerBedtime
Medication #6 Administration Type*

PillGummyLiquidPowderOther
Medication #6 Length of Time to Be Administered*
Will the camper take this medication for the whole summer, one week, etc?
How will you be sending medication #6 to camp?*

In the mailWith my camper
Medication #6 Special Instructions
Should be Empty: