PHYSICIAN’S MEDICATION ORDER FORM

This form is to be filled out by the parent, signed by the physician ordering medication, and retuned to jhcamp.

Please note, the first dose of any new medication must be administered at home.

The following medications must be given during the camp:

Medication Dosage and Time(s) to be given:

1.

2.

3.

Administration instructions (specify if to be taken with water, food, milk, etc.):

For medications listed above, please list all side effects that are to be monitored by camp personnel.

1.

2.

3.

List any reasons for not giving medications at the prescribed time (vomiting, fever, drowsiness, convulsions, etc.):

PHYSICIAN’S MEDICATION ORDER FORM (page two)

Physician’s Signature: Date:

Parental Authorization:

I / We authorize and request jhcamp to administer the medication(s) prescribed by our physician, and in so doing relieve the camp, its agents, employees, or representatives, of any responsibility for ill effects which may prevent from the administering of said prescribed medication as per the physician’s directions listed above.

Signature of Parent/Guardian Date