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Authorization to Administer Medication to a Camper

(completed by parent/guardian)

Date signed: May 28, 2022

First Camper's Name

First Name*

Last Name*
First Camper's Date of Birth*
First Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
First Camper's Signature*
Second Camper's Name

First Name*

Last Name*
Second Camper's Date of Birth*
Second Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Third Camper's Name

First Name*

Last Name*
Third Camper's Date of Birth*
Third Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Fourth Camper's Name

First Name*

Last Name*
Fourth Camper's Date of Birth*
Fourth Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Fifth Camper's Name

First Name*

Last Name*
Fifth Camper's Date of Birth*
Fifth Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Sixth Camper's Name

First Name*

Last Name*
Sixth Camper's Date of Birth*
Sixth Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Seventh Camper's Name

First Name*

Last Name*
Seventh Camper's Date of Birth*
Seventh Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Eighth Camper's Name

First Name*

Last Name*
Eighth Camper's Date of Birth*
Eighth Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Ninth Camper's Name

First Name*

Last Name*
Ninth Camper's Date of Birth*
Ninth Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Tenth Camper's Name

First Name*

Last Name*
Tenth Camper's Date of Birth*
Tenth Camper's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent/Guardian Additional Information

Home Phone:

Business Phone:

Emergency Telephone:
Licensed Prescriber Information

Name of Licensed Prescriber:

Business Phone:

Emergency Phone:
Authorization Information

I hereby authorize the health care consultant or properly trained health care supervisor at _________________________________________

to administer, to my child, ____________________________________ (Child's name)

the medication(s) listed above, in accordance with 105 CMR 430.160(C) and 105 CMR 430.160(D) [see below].

If above listed medication includes epinephrine injection system:

I hereby authorize my child to self-administer , with approval of the health care *
Yes
No
Not Applicable
I hereby authorize an employee that has received training in allergy awareness and epinephrine administration to administer *
Yes
No
Not Applicable

If above listed medication includes insulin for diabetic management:

I hereby authorize my child to self-administer , with approval of the health care consultant *
Yes
No
Not Applicable

** Health Care Consultant at a recreational camp is a Massachusetts licensed physician, certified nurse practitioner, or a physician assistant with documented pediatric training. Health Care Supervisor is a staff person of a recreational camp for children who is 18 years old or older; is responsible for the day to day operation of the health program or component, and is a Massachusetts licensed physician, physician assistant, certified nurse practitioner, registered nurse, licensed practical nurse, or other person specially trained in first aid.

105 CMR 430 References

105 CMR 430.160(A): Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the date of filling, the pharmacy name and address, the filling pharmacist’s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use. (M.G.L. c. 94C § 21).

105 CMR 430.160(C): Medication shall only be administered by the health care supervisor or by a licensed health care professional authorized to administer prescription medications. If the health care supervisor is not a licensed health care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health care consultant. The health care consultant shall acknowledge in writing a list of all medications administered at the camp. Medication prescribed for campers brought from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian.

105 CMR 430.160(D): A written policy for the administration of medications at the camp shall identify the individuals who will administer medications. This policy shall:

(1) List individuals at the camp authorized by scope of practice (such as licensed nurses) to administer medications; and/or other individuals qualified as health care supervisors who are properly trained or instructed, and designated to administer oral or topical medications by the health care consultant.

(2) Require health care supervisors designated to administer prescription medications to be trained or instructed by the health care consultant to administer oral or topical medications.

(3) Document the circumstances in which a camper, Heath Care Supervisor, or Other Employee may administer epinephrine injections. A camper prescribed an epinephrine auto-injector for a known allergy or pre-existing medical condition may:

a) Self-administer and carry an epinephrine auto-injector with him or her at all times for the purposes of self-administration if:

1) the camper is capable of self-administration; and
2) the health care consultant and camper’s parent/guardian have given written approval

(b) Receive an epinephrine auto-injection by someone other than the Health Care Consultant or person who may give injections within their scope of practice if:

1) the health care consultant and camper’s parent/guardian have given written approval; and
2) the health care supervisor or employee has completed a training developed by the camp’s health care consultant in accordance with the requirements in 105 CMR 430.160.

(4) Document the circumstances in which a camper may self-administer insulin injections. If a diabetic child requires his or her blood sugar be monitored, or requires insulin injections, and the parent or guardian and the camp health care consultant give written approval, the camper, who is capable, may be allowed to self-monitor and/or self-inject himself or herself. Blood monitoring activities such as insulin pump calibration, etc. and self-injection must take place in the presence of the properly trained health care supervisor who may support the child’s process of self-administration.

105 CMR 430.160(F): The camp shall dispose of any hypodermic needles and syringes or any other medical waste in accordance with 105 CMR 480.000: Minimum Requirements for the Management of Medical or Biological Waste.

105 CMR 430.160(I): When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned, it shall be disposed of as follows:

(1) Prescription medication shall be properly disposed of in accordance with state and federal laws and such disposal shall be documented in writing in a medication disposal log.
(2) The medication disposal log shall be maintained for at least three years following the date of the last entry.

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.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age: *

Diagnosis (at parent/guardian discretion):

Medication Information 1


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:

Medication Information 2


Name of Medication:

Dose given at camp:

Route of Administration:

Frequency:

Date Ordered:

Duration of Order:

Quantity Received:

Expiration date of Medication Received:

Special Storage Requirements:

Special Directions (e.g., on empty stomach/with water):

Special Precautions:

Possible Side Effects/Adverse Reactions:

Other medications (at parent/guardian discretion):

Location where medication administration will occur:
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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