Camper Medical Administration Form
Dates camper will attend camp
From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
General Information
Camper Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Must Be Completed for Campers Bringing Medication to Camp
Medication Name
Prescription
Non
Dosage
Reason medication is being administered
Date Taken at Home
-
Month
-
Day
Year
Date
Time/Frequency
Breakfast
Lunch
Dinner
Bed Time
Relevant side effects
None expected
Specify
Medication Name
Prescription
Non
Dosage
Reason medication is being administered
Date Taken at Home
-
Month
-
Day
Year
Date
Time/Frequency
Breakfast
Lunch
Dinner
Bed Time
Relevant side effects
None expected
Specify
Medication Name
Prescription
Non
Dosage
Reason medication is being administered
Date Taken at Home
-
Month
-
Day
Year
Date
Time/Frequency
Breakfast
Lunch
Dinner
Bed Time
Relevant side effects
None expected
Specify
Additional Comments
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Next
Licensed Medical Professional/Prescriber Section
Necessary for ALL prescription and Non-prescription medications administered at camp
Name
*
First Name
Last Name
Title
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Signature
*
Clear
Date
-
Month
-
Day
Year
Date
Back
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Parent/Guardian Section
Name
*
First Name
Last Name
Phone Number 1
*
-
Area Code
Phone Number
Phone Number 2
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
*
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: