BEULAH BEACH CAMP & RETREAT CENTER

MEDICATION AUTHORIZATION FORM

All campers under the age of 18years old who bring prescription or over-the-counter medications to be taken at camp require aMedication Authorization Form on file. AMedication Authorization Form must be completed and signed by the parent/guardian forover-the-counter medications or parent/guardian and Doctor or NursePractitioner for prescription medication. Campers may not keep and take medications on their own (exception is made for asthmainhalers and epi pens as indicated below in thehealth care provider section). Allmedications are to be given to the Camp Nurse at the time ofregistration. All over-the-countermedications must be received in the original package containingdirections for dosage. All prescriptionmedications must be received in the original pharmacy bottle labeledwith the camper’s name and a current expiration date. NO MEDICATION WILL BE RECEIVED ORADMINISTERED IF BROUGHT IN A PILL ORGANIZER,BAGGIE, OR OTHER CONTAINER. Thisauthorization is valid for the camp year 2008. Any additions or changes in medication, dosage or time of administrationrequires a new form completed and signed by the parent/guardian and health careprovider.

PARENT/GUARDIANSECTION:

I, the undersigned aslegal parent/guardian of __________________________________,

date of birth _______, attending ________________ (camp),dates _________________,

request the Camp Nurse (or designee under the direction of the Camp Nurse) administer the following listed medication(s) to mychild . I authorize, as needed, thesharing of information related to my child’s health between the Camp Nurse (or designee) and thehealth care provider listed below.

_______ ____________________________________________________________

Date Printed name and signature ofParent/Guardian

__________________________________ _________________ _________________

HomeAddress Contact phone # 1 Contact phone # 2

I hereby instruct the Camp Nurse (or designee) to assist the above camper in taking:

Medication Dosage Route Time Diagnosis/condition:

___________________________ _________ __________ ______________________________

___________________________ _________ __________ ______________________________

___________________________ _________ __________ ______________________________

___________________________ _________ __________ ______________________________

___________________________ _________ __________ ______________________________

HEALTH CARE PROVIDER SECTION:

In my professionalopinion, this camper may carry and self-administer an asthma inhaler and/or epi pen. YES NO N/A

________________________________________ ____________________________________

Printed name of healthcare provider Address& Telephone #

________________________________________ _____________________

Signature of healthcare provider Date