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
Other
Relevant side effects
1
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
Other
Relevant side effects
2
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
Other
Relevant side effects
3
None expected
Specify
Additional Comments
Back
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
*
Format: (000) 000-0000.
Signature
*
Date
-
Month
-
Day
Year
Date
Back
Next
Parent/Guardian Section
Name
*
First Name
Last Name
Phone Number 1
*
Format: (000) 000-0000.
Phone Number 2
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: