Download Report

MEDICATION ADMINISTRATION
AUTHORIZATION FORM
Department of Health & Mental Hygiene (DHMH)
Center for Healthy Homes and Community Services (CHHCS)
6 St. Paul Street, Suite 1301
Baltimore, Maryland 21202-1608
(410) 767-8417 FAX (410) 333-8926
Toll Free 1-877-4MD-DHMH ext. 8417
I. CAMP OPERATOR
This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the
camper to self administer medication. A new medication administration form must be completed at the beginning of each camp season,
for each medication, and each time there is a change in dosage or time of administration of a medication.
•
Prescription medication must be in a container labeled by the pharmacist or prescriber.
•
Nonprescription medication must be in the original container with the instructions for use. Nonprescription medication includes
vitamins, homeopathic, and herbal medicines.
•
An adult must bring the medication to the camp and give the medication to an adult staff member.
II. CAMP INFORMATION
YOUTH CAMP NAME
PHYSICAL ADDRESS
CITY
STATE
ZIPCODE
III. PRESCRIBER'S AUTHORIZATION
CHILD'S NAME
DATE OF BIRTH
CONDITION FOR WHICH MEDICATION IS BEING ADMINISTERED:
EMERGENCY MEDICATION
[ ] YES
MEDICATION NAME
DOSE
[ ] NO
ROUTE
TIME/FREQUENCY OF ADMINISTRATION
IF PRN, FREQUENCY
IF PRN, FOR WHAT SYMPTOMS
KNOWN SIDE EFFECTS SPECIFIC TO CHILD
MEDICATION SHALL BE ADMINISTERED
FROM
TO
(NOT TO EXCEED 1 YEAR)
PRESCRIBER'S NAME/TITLE
This space may be used for the Prescriber's Address Stamp
TELEPHONE
FAX
ADDRESS
CITY
STATE
ZIPCODE
PRESCRIBERS SIGNATURE (Parent cannot sign here)
DATE
(ORIGINAL SIGNATURE OR SIGNATURE STAMP ONLY)
IV. PARENT/GUARDIAN AUTHORIZATION
I request authorized youth camp operator/staff to administer the medication as prescribed by the above prescriber. I certify that I have legal
authority to consent to medical treatment for the child named above, including the administration of medication at the facility. I understand that at
the end of the authorized period, an adult must pick up the medication, otherwise it will be discarded. I authorize camp personnel to communicate
with the prescriber as allowed by HIPAA. I confirm that, if the medication above is a prescription medication, the child has at some point taken the
medication prior to attending camp.
PARENT/GUARDIAN SIGNATURE
DATE
CELL PHONE #
HOME PHONE #
WORK PHONE #
V. AUTHORIZATION FOR SELF ADMINISTRATION AND SELF CARRY
I consent that the child named above is able to self administer the medication listed. I authorize self administration of the above listed medication for
the child named above under the supervision of an authorized youth camp operator/staff member. The child named above may self carry emergency
medication if indicated below.
PRESCRIBER'S SIGNATURE
SELF CARRY EMERGENCY MEDICATION (Check One)
[ ] YES
PARENT/GUARDIAN'S SIGNATURE
[ 1 NO
DATE
[ ] Not emergency medication
SELF CARRY EMERGENCY MEDICATION (Check One)
[ 1 YES
DHMH #
[ ] NO
DATE
[ ] Not emergency medication
Page 1
CAMP PERMISSION TO RELEASE FORM
My child
permission to be released to following individuals:
Please Note, your child will not be released to any other
person(s) unless they are written on the above list.
Additionally, I.D will be required at the time of pick - up.
Parent Signature:
Date:
Staff Signature:
Date:
has
CAMPER HEALTH HISTORY
Child's Name:
The following information is required:
1st Emergency Contact
(Parent or Legal Guardian):
Phone:
2nd Emergency Contact
(Other than Parent Above):
Phone:
Child's Physician:
Phone:
HEALTH INFORMATION.
1. Are there any health problems including physical, psychiatric, or behavioral problems of
which we need to be aware?
❑ NO
❑ YES, Explain:
2. Are there any medications, dietary restrictions, allergies, or special needs that we need to
❑ NO
be aware of to ensure that your child's camp experience is positive?
❑ YES, Explain:
IMMUNIZATION INFORMATION:
For campers who reside within the
United States, a United States territory,
or the District of Columbia:
<
013> For campers who reside outside the
United States, a United States territory,
or the District of Columbia:
1. State/territory in which child resides:
1. Country in which child resides:
2. Is this child exempt from any
[ ] NO
immunizations?
[ ] YES, List them:
2. Attach Department form DHMH-896
(record of vaccination or immunity)
Parent or Legal Guardian's Signature:
Date:
ALL PRO GYMNASTICS AND CHEER ACADEMY'S SUMMER CAMP REGISTRATION FORM
6685 SANTA BARBARA CT., ELKRIDGE, MD 21075
(PHONE)410-379-5439
(FAX)410-379-5449
CHILD'S NAME
DATE OF BIRTH
AGE
SEX
ADDRESS
CITY
STATE
HOME PHONE
EMAIL
MOM'S NAME
DAD'S NAME
MOM'S CELL
DAD'S CELL
ZIP
ALLERGIES/MEDICAL
CONDITIONS
EMERGENCY CONTACT/PHONE
Full
DAY
9am-4pm
Half
AM
9am-12pm
Half
PM
1pm-4pm
Extended
AM
8am-9am
Extended
PM
4pm-6:30pm
Full
DAY
9am-4pm
Half
AM
9am-12pm
Half
PM
1pm-4pm
Extended
AM
8am-9am
Extended
PM
4pm-6:30pm
$270
week
$205
week
$205
week
$30
week
$75
week
$270
week
$205
week
$205
week
$30
week
$75
week
June 15-19
July 20-24
June 22-26
July 27-31
June 29-July 3
August 3-7
July 6-10
August 10-14
July 13-17
August 17-21
Date
Date
Cost
Deposit
Balance Paid
Discount
Balance Due
cash / check #
cash / check #
/ Charge
/ Charge
There is $100 deposit for each camp chosen, Balance for all camps are due on the Monday of the week your child is to attend camp. Please note that there will be a
$25.00 late fee for all monies not collected on the due date. Please understand that you are paying for your child's spot in a camp NOT their attendance. Additionally, I
understand that if my child is not picked up on time by the end of the camp
Release agreement: I understand that any athletic activity is inherently dangerous. The above named student has had a medical examination within the last twelve months
and is capable of participating in gymnastics. In the event of injury or illness, every effort will be made to contact the parent or guardian. If necessary, I authorize All Pro
Gymnastics & Cheer Academy to administer first aid and/or authorize medical treatment. Students are expected to carry their own accident and medical insurance. I
agree to be responsible for any medical bills incurred resulting from illness or injury during my child's participation at All Pro Gymnastics & Cheer Academy and hold
harmless All Pro Gymnastics and Cheer Academy and all staff, employees. sub-contractors and owners for any injuries resulting in my child's participation including but
not limited to death. BY SIGNING THIS RELEASE, I UNDERSTAND THE POLICIES AND LIABILITIES THAT MAY OCCUR IN SPORTS ACTIVITIES.
Additionally, I have read and understand the rules and policies as they apply to attendance and payment. I UNDERSTAND THERE ARE NO REFUNDS OR CREDITS
GIVEN.
Photograph Release: I agree to allow my child's likeness to be used on the website and in promotional materials for All Pro Gymnastics & Cheer Academy
Date
Parent Signature
Credit Card Information: (Please fill out below when mailing in payment)
CC#
Signature
STAFF ONLY:
Date RCVD
Child Release
Health History
Date RCVD
Medication Admin. Date RCVD
Zip Code
exp Date:
Date