AUTHORIZATION TO ADMINISTER MEDICATION TO A CHILD

(To be completed by parent/guardian)

Name of Child: ________________________   Age: ______

Parent/Guardian Name: ______________________ Emergency Telephone: ______________________

Home Telephone: ___________________________ Business Telephone: ________________________

Child’s Food/Drug Allergies:

____________________________________________________________________________________

#1 Name of Medication:                                 Dose given at studio:

Frequency:                                                 Date Ordered Duration of Order:

Expiration date of Medication:                         Special Storage Requirements:

Specific Directions (e.g., on empty stomach/with water):

Specific Precautions:                                        Possible Side Effects/Adverse Reactions:

Name of Licensed Prescriber:                         Business Telephone:

Diagnosis/reason for medication

__________________________________________________________________________________________________________________

#2 Name of Medication:                                 Dose given at studio:

Frequency:                                                 Date Ordered Duration of Order:

Expiration date of Medication:                         Special Storage Requirements:

Specific Directions (e.g., on empty stomach/with water):

Specific Precautions:                                        Possible Side Effects/Adverse Reactions:

Name of Licensed Prescriber:                         Business Telephone:

Diagnosis/reason for medication

__________________________________________________________________________________________________________________

#3 Name of Medication:                                 Dose given at studio:

Frequency:                                                 Date Ordered Duration of Order:

Expiration date of Medication:                         Special Storage Requirements:

Specific Directions (e.g., on empty stomach/with water):

Specific Precautions:                                        Possible Side Effects/Adverse Reactions:

Name of Licensed Prescriber:                         Business Telephone:

Diagnosis/reason for medication

__________________________________________________________________________________________________________________

Listed above, in accordance with 105 CMR 430.160.  105 CMR 430.160(A)

Medication prescribed for Child shall be kept in original containers bearing the pharmacy label, which shows the date of filling, the pharmacy name and address, the filling pharmacist’s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for Child shall be kept in the original containers containing the original label, which shall include the directions for use.105 CMR 430.160(C)

Medication shall only be administered by the health supervisor* or by a licensed health care professional authorized to administer prescription medications. The health care consultant shall acknowledge in writing the list of medications administered at the camp. If the health supervisor is not a licensed health care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health care consultant. Medication prescribed for Child's brought from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian. 105 CMR 430.160(D)

When medication is no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned, it shall be destroyed.

Authorization to Administer Medication to a Child.  I hereby authorize Scrap U & Artistry Too to

administer, to my child, _________________________ the medication(s) listed above.

(NAME OF CHILD)

Parent/Guardian Signature: ________________________________ Date: _______________________ 

856 Route 206, Building C, Suite 20, Hillsborough, NJ 08844   www.scrapunj.com  732-239-5003   tina@scrapunj.com