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 personel at the time of arrival in the original container,

whether it is a prescription or over the counter medication.

I, the parent/legal guardian of the camper named on this form. Give my permission for the personnel at Tulakogee to:

1. Dispense Tylenol or Advil (or its generic equivalent) to camper for headache, fever, or minor pain:

2. Dispense Benadryl (or its generic equivalent) to camper for allergic reactions:

3. Dispense Tums, Kaopectate, or Pepto Bismol (or its generic equivalent to camper for upset stomach;

4. Dispense Hydrocortisone Cream or other antibiotic ointment for minor injuries;

5. Dispense prescription or other over-the-counter medication designated by and produced by the parent/guardian or family physician

Name of Child ___________________________________________________________________

Age: ___________ Weight: _____________ 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: ______________________________________

______________________________________________________________________________

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

MEDICATION MUST BE BROUGHT IN THE ORIGINAL CONTAINER