Medication Administration Form
Please complete one form for each medication
What camp is your child attending?
*
July 2-4: Camp Rainbow
July 6-10: Leadership
July 13-17: Intermediate
July 20-22: Junior Camp A
July 22-24: Junior Camp B
July 27-31: Teen
August 3-7: Intermediate
August 10-12: Junior Camp C
August 17-21: Intermediate
August 24-28: Teen
August 31-Sept 4: Intermediate
Child's Full Name
*
First Name
Last Name
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Medication Name
*
Is this medication to be given daily or as needed?
*
Daily
As needed
If medication is as needed, please describe the circumstances for administration.
*
How many times per day should the medication be given? (Frequency)
*
Dose (amount and units)
*
Should this medication be taken with food?
*
Yes
No
Other
Timing and relation to food for medication intake (select all that apply):
Rows
Before food
With food
After food
Breakfast
Lunch
Supper
Bedtime
Additional information or instructions for staff
Signature
For staff only
Rows
M
T
W
Th
F
Breakfast
Lunch
Supper
Bedtime
Submit Medication Record
Submit Medication Record
Should be Empty: