Sr_medform1

Section 1:
Written Parent/Guardian Consent for Administration of Over-the-Counter Medications
for ________________________________________________________________________
Camper’s Name
I hereby authorize, by my signature below, the BCWS health and administrative staff to give the above named
camper the following during program hours (please check appropriate spots and sign below):
Antacid for gastric discomfort ____ ____ Ibuprofen for pain/temperature ____ ____ Acetaminophen for pain/temperature ____ ____ Decongestant for nasal congestion ____ ____ Creams for generalized or local reactions ____ ____ X_________________________________________________________ _____________________ ____________________________________ Signature of Parent or Guardian Date Instructions:
Section 2 and 3 of this form must be filled out for each medication that the camper needs. Please
call 703.842.0470 if you need additional copies.

Section 2:
Written Parent/Guardian Consent for Administration of Prescriptions

This form must be completed for each prescription medication.
1. I give permission to have the BCWS Directors or personnel designated by the BCWS Directors give
the medicine_____________________________________________________________________
__________________________________________ to ________________________________ Prescribed by Camper’s Name 2. I give permission for my son/daughter to self-administer medication if the BCWS Directors determine it is safe and appropriate. Yes ________ No ________ 3. I give permission to the BCWS Directors to share with appropriate BCWS personnel information relative to the prescribed medicine administration, e.g. adverse side effects, as determined necessary for my son/daughter’s health and safety. Yes ___________ No ____________
Any restrictions on release _________________________________________________________
_______________________________________________________________________________
I understand that I may retrieve the medication from BCWS at any time and that the medicine will be
destroyed if it is not picked up within one week following termination of the order or two days beyond
the close of BCWS.
Please note: ALL MEDICATIONS RECEIVED BY BCWS STAFF MUST BE IN THE ORIGINAL
CONTAINER FROM THE PHARMACY. THE LABEL MUST BE CLEAR AND CORRECT IN
ORDER FOR THE STAFF TO ADMINISTER MEDICATIONS.
X____________________________________________________________
Signature of Parent of Guardian


Relationship to Student_________________________________ Date_____________________
Section 3: Medication Order
A licensed prescriber, physician, or nurse practitioner must complete this form for each medication.
Name of camper________________________________________ Date of birth_________________
Address___________________________________________________________________________
Name of licensed prescriber____________________________Title___________________________
Business telephone number_________________ Emergency telephone number__________________
MEDICATION_____________________________________________________________________
Route of administration_______________________Dosage_______________Frequency___________
Time(s) of administration____________________________Date of order_______________________
Discontinuation date_________________Diagnosis________________________________________
Any other medical condition___________________________________________________________
__________________________________________________________________________________ Optional information_________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 1. Special side effects, contraindication, or possible adverse reactions to be observed______________ __________________________________________________________________________________ 2. Other medication being taken by the camper_____________________________________________ __________________________________________________________________________________ 3. The date of the next scheduled visit or when advised to return to prescriber____________________ 4. Consent for self-administration (provided the BCWS Directors determine it is safe and appropriate). Yes__________________ No_________________ __________________________________________________________ Signature of licensed prescriber

Source: http://www.burgundycenter.org/senior/SR_medForm11.pdf