Prescription Medication

1 General information
2 medication
3 legal agreement

Squash and Beyond

Camps at Williams College

Prescription Medication Form
Personal Information
Camper's NameFull name please
ContactPhone number
Commentsmore details
0 /
Logistics and Medical Information
Camp Name
Start Dateof Camp
End Dateof Camp
Medicationsingle medication
Dosageamount in oz.
Dosagetimes per day
Comments/DirectionsSpecial instructions
0 /

I hereby give permission for authorized camp officials to administer the above medication to my child.

Nameyour full name
Dateof form completion

(A)  Medication prescribed for campers 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 prescribed 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 campers shall be kept in the original containers containing the original label, which shall include the directions for use. 

(B) All medication prescribed for campers shall be kept in a locked storage cabinet used exclusively for medication, which is kept locked except when opened to obtain medication. The cabinet shall be substantially constructed and anchored securely to a solid surface. Medications requiring refrigeration shall be stored at temperatures of 38° to 42°F in a locked box, used exclusively for medications, and physically affixed to the refrigerator.

(C) Medication shall only be administered by the health supervisor or by a licensed health care professional authorized to administrator prescription medications. 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. The health care consultant shall acknowledge in writing a list of all medications administered at the camp. Medication prescribed for campers brought from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian.

(D) When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned, it shall be destroyed as follows:

(1) Destruction of prescription medication shall be accomplished by the health care consultant, witnessed by a second person and recorded in a log maintained by the camp for this purpose. Said log shall include the name of the camper, the name of the medication, the quantity of the medication destroyed, and the date and method of destruction. The health care consultant and the witness shall sign each entry in the medication destruction log. 

(2) The medication log shall be maintained for at least three years following the date of the last entry. 

* One form must be completed for each medicine

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