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Medication Administration Form

Child's Name: __________________________________ Date: ___________________

Last First Init.

Age: ______________________

Camp Group (if known): _____________________

I authorize the Nurse at Adventureland Day Camp to administer:

1. ____________________________________ to ___________________________ in (Name of Medication)* (Child's Name) this dose___________________________from_________________to______________ (date) (date) Times: _____________________________ Purpose: ________________________ Special Instructions: __________________________ Side Effects: _______________ 2. ____________________________________ to ___________________________ in (Name of Medication)* (Child's Name) this dose___________________________from_________________to_____________ (date) (date) Times: _____________________________ Purpose: ________________________ Special Instructions: __________________________ Side Effects: _______________ ______________________________ (Parent / Guardian Signature)

*Prescription medication(s) MUST be in original container with physician's label clearly visible in childproof bottle.

If camper is leaving before last day of camp please indicate date any remaining medicine should be sent home _______________. Date

* Note: Return this form with any medications on the First Day of camp your camper (s) attend. If camper is NOT on medication, please keep these forms for future use if needed.

Par Doc-6

Mail To: Adventureland Day Camp 97 Fieldstone Road Levittown, PA 19056

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Microsoft Word - (Med Admin Form).doc