Gray Recreation Summer Camp
Medical Treatment and Medication Authorization Form
The Gray Recreation Summer Camp requires the following information regarding medication needs of participants in the program. Please note the following policies:
Each medication (i.e. prescription and over the counter) to be taken or medical devises/procedures/inhalers/Epi-Pens used during program hours should follow the same rules enforced through MSAD 15.
For campers these items must not be stored in the child’s possession and should be delivered via parent/guardian directly to a staff member for locked storage. For the safety of your child as well as the safety of all other campers on site, no medication of any kind may be left unlocked or unsupervised.
Summer Camp Staff are authorized to administer medication. They will supervise the taking of medication for the participant and medication listed below.
Parents/guardians are solely responsible for ensuring that adequate medication is provided in a secured container labeled with your child’s name, the name of the medication, the dosage amount and the time or times to be taken.
Medical personnel are not on staff during this program.
A separate form must be filled out for each medication needed and each time one is left or picked up at the program.
Failure to comply with the above rules may jeopardize your child’s right to attend the Summer Camp Program. We reserve the right to dismiss children from the program (without a refund) at any time.
Child’s Name:__________________________________________________________________________
Name of Medication:____________________________________Dosage Amount:__________________
Frequency of Dosage:___________________________________________________________________
Time(s) to be taken during camp:________________________________________________________
Duration of treatment:_________________________________________________________________
Possible side effects and adverse reactions (if any):____________________________________________