Required fields are marked with asterisks (*)

Camp Medical Administration Request Form

This form is to be completed for any child that requires medication during camp hours. This personal information and personal health information is being collected, used and disclosed to program staff for the purpose of administering medication.

Name of Child:

Date of Birth:

Camp(s) attending:

Medical Alert I.D.:

Yes

Name of Medication (as it appears on the label):

Prescription or non-prescription?:

Dosage and Route:

Time of administration:

Possible side effects (if any):

Storage Instructions:

I authorize the Kawartha Lakes Parks and Recreation staff to (please select appropriate box):

Supervise the named participant in the administration of their own medication.

Administer medication to the named participant.

Medication Administration Start Date:

Medication Administration End Date:

Parent/Guardian Authorization

Full name of authorizing Parent/Guardian:

Relationship to child:

Phone Number:

Today's Date:

Parent/Guardian Signature:

Clear

Personal information contained on this form is collected in pursuant to the Municipal Act, 2001 and will be used for the purpose of responding to your request. Questions about the collection of this information should be directed to the City Clerk or Deputy-Clerk at clerks@kawarthalakes.ca.