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Medication Consent Form

This form is used to provide consent for Mohawk Country Day School camp personnel to administer both prescription and over-the-counter medications to children. It requires the name of the child and medication, dosage, time to be administered, reason for medication, and signatures from the parent/guardian and physician to grant permission for camp staff to administer the specified medication as labeled and contact the physician if needed.

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arthur_rotfeld
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2K views1 page

Medication Consent Form

This form is used to provide consent for Mohawk Country Day School camp personnel to administer both prescription and over-the-counter medications to children. It requires the name of the child and medication, dosage, time to be administered, reason for medication, and signatures from the parent/guardian and physician to grant permission for camp staff to administer the specified medication as labeled and contact the physician if needed.

Uploaded by

arthur_rotfeld
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Medication Consent Form: This form allows parents to give consent for medication administration at Mohawk Day Camp.

Mohawk Day Camp Mohawk Country Day School

MEDICATION CONSENT FORM


Required for both prescription and over-the-counter medications;
please use a separate form for each medication.

Use this form to give your consent for medication to be administered at Mohawk.

Childs Name:

______________________________

Name of Medication:

______________________________

Dose to be given:

______________________________

Time to be given:

______________________________

Reason for medication:

______________________________

Medication must be ordered/advised by a physician/dentist.


Medication must be brought to Mohawk in original container with
appropriate label intact. If medication is not properly labeled,
it will not be administered.
Parent/guardian and physician must sign this form granting Mohawk
personnel permission to administer medication.
I give my permission for Mohawk personnel to administer
the above mentioned medication to my child,
and to contact the physician/dentist if necessary.
Parent/Guardian
Signature:

___________________________

Physician/Dentist
Signature: ______________________________

Please print: ___________________________

Please print: ___________________________

Date: ____________

Date: ____________

U:\~Camp\Medical\current medical forms\Parent Medication Consent Form.doc

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