Tulakogee Conference CenterA website for our guests at Tulakogee

Medical Authorization form (Click this link for a word document form)

Medical Authorization form PDF file

KMAK

PARENTAL AUTHORIZATION TO ADMINISTER MEDICATION

This medication form must accompany ALL medication to be given at KMAK.

All medications MUST be given to the Camp First Aid person at the time of arrival in the original container, whether it is a prescription or over the counter medication.

I hereby give my permission to the Camp First Aid person and to designated camp staff to administer medication to my child at KMAK.

Name of Child _________________________________________________

Age:  ___________ Weight:  _____________

Church name:____________________________________________________________ City:_____________________________________

I understand that the camp first aid person and/or the KMAK staff shall not be liable to the student, parent, or guardian of the child for civil damages for any personal injuries to the student, which result from acts or omissions in administering any medication at KMAK.

_______________________________________________ _________________________

Signature of Parent or Legal Guardian & Date

MEDICINE MUST BE BROUGHT IN THE ORIGINAL CONTAINER

Name of medication(s): _______________________________________________________

Reason for medication to be given and/or comments: ________________________________________

Time(s) to administer medication at camp: __________________________________________

Dates to administer medication at camp: ___________________________________________

Side effects to be reported to parents: ____________________________________________________

Side effects requiring immediate medical attention: ______________________________________

List of medications:

1)_________________________________________________________________________

2)_________________________________________________________________________

3)_________________________________________________________________________

4)_________________________________________________________________________

A.M. Breakfast                  Noon Lunch                     P.M. Dinner                                 Bed Time

Notes from first aid person: __________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

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