Request for Administration or Self-Administration of Prescription Medication

Camper's First Name*

Camper's Last Name*

Parent/ Guardian Name, who has the legal authority to consent to medical treatment for the camper named above, including the administration or self-administration of medication*

Parent/ Guardian's Email*

Fill this form out ONLY if your child requires carrying any medication while at camp

FORM 1. REQUEST FOR ADMINISTRATION OF PRESCRIPTION MEDICATION

This form provides permission to employees of DiscoveryLand Camp to administer medication to campers during camp hours as per details provided below. The parent/guardian of a camper with a serious health concern is responsible for providing, in advance, medication/supplies for any treatment required in a life-threatening situation. Bring your child's medications in a plastic zip locked bag with your child's name on it. Put it in your child's bag and ask her/him to give it to the Camp Counsellor when asked, for storing after arrival. All medications must be in an original container with a currently dated, accurate pharmacy label.

Our employees are instructed to follow the doctor's or parent's/guardian's instructions explicitly. Persons dispensing medications are not medically trained health care professionals and cannot be held responsible for any conditions that may arise from the administration of the medication to a camper.

MEDICATION 1:

Name of medication

Health concern for which medication is to be given

Dosage

Time to be given

Expected side effect (if any)

MEDICATON 2:

Name of medication

Health concern for which medication is to be given

Dosage

Time to be given

Expected side effect (if any)

MEDICATON 3:

Name of medication

Health concern for which medication is to be given

Dosage

Time to be given

Expected side effect (if any)

By SUBMITTING this form I hereby give permission to DiscoveryLand Camp Staff to administer the above listed medication prescribed for my child.

FORM 2. AUTHORIZATION FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION

Fill this form out ONLY if your child requires carrying any medication while at camp and can SELF-MANAGE care and delivery of medication

Bring your child's medications in a plastic zip locked bag with your child's name on it. Put it in your child's bag.

MEDICATION 1:

Name of medication

Health concern for which medication is to be given

Dosage

Time to be given

Expected side effect (if any)

MEDICATION 2:

Name of medication

Health concern for which medication is to be given

Dosage

Time to be given

Expected side effect (if any)

MEDICATION 3:

Name of medication

Health concern for which medication is to be given

Dosage

Time to be given

Expected side effect (if any)

By SUBMITTING this form I authorize and recommend self-medication by my child for the above medication. I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending physician. I shall indemnify and hold harmless the DiscoveryLand Camp Staff, against any claims that may arise relating to my child’s self-administration of prescribed medication(s). My child is instructed not to share this medication with anyone.

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