COUNCIL POLICY ON PRESCRIPTION MEDICATION AT CAMP

To prevent problems with administration of medication, your son MUST have 
a medication form completed by his physician for any prescription medication.
The medication Form is printed on the reverse side of this letter. Medication 
will not be administered to your son unless Camp Sequassen is in receipt
of this form.

PLEASE STAPLE THIS FORM TO MEDICAL FORM

Authorization for the Administration of Medications by Camp Personnel

The Connecticut State Law and regulations require a physician's or dentist's 
written order and parent and/ or guardian authorization for a Camp Health
Officer to administer medications, or, in their absence, Administrative Camp
Staff to administer medications. Medications must be pharmacy prepared containers
and labeled with the name of the child, name of the drug, strength, dosage, 
frequency, physician's or dentist's name and date of original prescription.

Physician's or Dentist's Order:
Child's Name: _________________________________________ Date: ______________
Address: ___________________________________________________________________
Date of Birth: _____/ _____/ _____
Drug name, dosage and method of administration: ____________________________
Condition for which drug is being administered during camp: ________________
Time(s) of administration: _________________________________________________
Medications shall be administered from: Date: _________ to Date: ___________
Relevant side effects to be observed, if any: ______________________________
If there are any side effects, plan for management: ________________________
Is this a controlled drug? ____ If yes, DEA Number _________________________
Physician/ Dentist Name (Print): ___________________________________________
Phone: _____________________________________________________________________
Address: ___________________________________________________________________
physician or Dentist Signature: ____________________________________________
Date: ______________________________________________________________________

_____________________________________________________________________________

Authorization by Parent/ Guardian

_____________________________________________________________________________

To:  Camp Personnel
Date:____/ ____/ ____

I hereby request that the above medication(s), ordered by the physician/ dentist
for my child _______________________ (son's name), be administered by camp
personnel. I understand that I must supply the camp with prescription medication
in the original container and properly labeled by a physician or pharmacist
and will provide not more than seven (7) days supply of said medication(s).

I understand that this medication will be destroyed if it is not picked up
within one week after my son leaves camp.

Parent/ Guardian Name (print): ___________________________________________

Signature: _______________________________________________________________

Relationship to Child: ___________________________________________________

RETURN