Authorization to Administer Medication - Tilth Alliance

Please list ALL medication (both prescription and over-the-counter drugs) your child will need to take during camp.
Prescription medication must be in its original container with child’s name, prescribing physician, name of medication, dosage and frequency of administration clearly visible on the packaging.
Please ensure that medications have not expired.
Medication that is not labeled, is out of date or not in its original container will NOT be administered.

"*" indicates required fields

Child's Name*

First Last

Parent's/Guardian's Name*

First Last

Email*

Phone

Medications

Name of Medication #1

Dosage*

Reason for Taking*

Time Taken*

Name*

Initials*

Name of Medication #2

Dosage

Reason for Taking

Time Taken

Name

Initials

Name of Medication #3

Dosage

Reason for Taking

Time Taken

Name

Initials