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This form must be filled out if you selected that you would like the Baroody Camps, Inc. On-Site Coordinator to adminster and store your child's Medication during Enrichment programs for the duration of the session.

Please read for EpiPens:

  1. Epinephrine may be given during Enrichment programs only with parent or guardian-signed authorization.
  2. This waiver must be on file with Baroody Camps, Inc.
  3. A new waiver must be submitted to the school each school year and whenever there is a change in the dosage or a change in the conditions under which epinephrine is to be injected.
  4. Physician information necessary includes: Name of student, specific allergen(s) for which epinephrine is being prescribed, route of exposure (e.g. ingestion, skin contact, inhalatoin, or insect sting or bite), brand name of medication, amount of premeasured epinephrine, time for repeated dose if deemed necessary, duration of medication order and effective dates, physician signature and date.
  5. Only premeasured doses of epinephrine may be given by Baroody Camps, Inc. during Enrichment programs before or after school.
  6. Medication must be properly labeled by a pharmacist. If a physician?s orders include a repeat of the epinephrine injection, then the parent or guardian must supply the school with two epinephrine autoinjectors. Expiration date must be clearly indicated on the pharmacy label or autoinjector. The parent must provide a replacement epinephrine autoinjector when notified that the current autoinjector has expired or has been administered.
  7. Epinephrine must be hand-delivered to the Baroody Camps, Inc. On-Site Coordinator by the parent or guardian unless approved for the student to carry during Enrichment programs before or after school.
  8. Unless the student has been authorized to carry epinephrine, the parent or guardian is to collect any unused epinephrine within one week after the end of expiration of the order or on the last day of school. Epinephrine not claimed within that period shall be destroyed.

 

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
MEDICATION AUTHORIZATION FORM (for Prescription and Non-Prescription Medications)

Student's First & Last Name *

Name of medication(s): *

Dosage to be administered *

Time to be administered *

Special instructions (if any): *

This authorization is effective from: (start date) *

This authorization is effective until: (end date) *

**Since this authorization is for long-term medication (lasting more than 10 working days), all information below must be submitted by the parent/guardian AND in writing from your child's physician.**

By signing this waiver, I hereby acknowledge I have read the above information. I agree to release, indemnify and hold harmless, Baroody Camps, Inc., the School, the School's Parent Teacher Association, and its agents, officers, and employees from lawsuits, claims, expenses, demands, or actions, etc. against them for administering any medications. I have read the procedures outlined on this form and assume responsibility as required.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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