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Medication Administration Request Form - Camp

I agree to provide Recreation Services Staff with:
- All non-prescription medication in its original container dated and labeled with the Participants name. I understand that Recreation Services Staff has the right to ask for a physician’s order before agreeing to administer, store or supervise the administration of nonprescription medication.
- All prescription medication in the original container dated, labeled and supplied by the pharmacist. The label will contain: the Participant’s name, the physician’s name, the name of the medication, the dose, the medication route, the schedule for administration and instructions for storage.
- Two current photographs if there is a requirement to administer emergency medication, i.e. EpiPen. I understand that one photograph will be affixed to this form and one will be affixed to the Medication Log.
I agree that City of Oshawa Staff may refuse to administer, supervise the administration or store medication where the label(s) on the medication container(s) do not contain all the information specified above.
I understand that none of the City of Oshawa Staff are trained health professionals and that the administration of medication is being provided by City of Oshawa Staff on a purely voluntary and gratuitous basis. As the Participant or Parent/Guardian of the Participant receiving medication, I fully understand the nature and extent of the risks involved in administering medication.

I confirm that I have read and understood and completed this agreement. I am aware that by signing this agreement I have agreed to assume full legal liability for all risks involved in having the City of Oshawa administer medication under the provisions of this agreement to the named Participant.

I authorize the City of Oshawa’s Recreation Services Staff to (please check the appropriate box):

Supervise the named Participant in the administration of his/her own medication

Administer medication to the named Participant

Camper First Name

Camper Last Name

Medication Log

To be completed by the Participant or Parent/Guardian of the Participant.

Camper's Date of Birth

Name of medication as it appears on the label

Possible Side Effects (if any)

Administration Schedule (Time to be given)

Dosage & Route

Storage Instructions

Please indicate special instructions for taking medication (i.e. with meals, drink plenty of water):

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This form may contain personal information as defined under the Municipal Freedom of Information and Protection of Privacy Act. This information is collected under the legal authority of the Municipal Act, 2001, S.O. 2001 c.25, as amended. This information will be used and maintained by the City of Oshawa to provide camp staff permission to administer medication. Questions regarding this collection may be directed to the City’s Information Access and Privacy Officer at 905-436-3311.