Prescription Medication Form
I, hereby, ________________________________ (Parent/Guardian Name) give the camp health supervisor/athletic trainer permission to hold on the prescription medication and administer as indicated by the prescription. I further acknowledge this medication was prescribed by a licensed physician and that the camp health supervisor may contact that physician with any questions or concerns.
My child’s name is __________________________ and the medication my child will be taking is as follows:
The medication is to be given ____________________ time(s) per day.
Please list any other additional information regarding the prescription medication (Please indicate if there is none):
Furthermore, the medication will be kept by the healthcare supervisor/athletic trainer during each session and secured in a locked location overnight. Please be advised that only the amount of medication needed for the duration of the camp should be provided.
Relationship to Camper: