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Medication Administration Authorization Form

  • I. Camp Operator

    This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the camper to self administer medication. A new medication administration form must be completed at the beginning of each camp season, for each medication, and each time there is a change in dosage or time of administration of a medication.
    • Prescription medication must be in a container labeled by the pharmacist or prescriber.
    • Nonprescription medication must be in the original container with the instructions for use. Nonprescription medication includes vitamins, homeopathic, and herbal medicines.
    • An adult must bring the medication to the camp and give the medication to an adult staff member.

  • II. Camp Information


  • III. Prescriber's Authorization

  • (Not to exceed 1 year)
  • (Not to exceed 1 year)
  • IV. Parent / Guardian Information