PLEASE COMPLETE AND EMAIL TO DOCS@MASSATHLETE.COM OR BRING TO CAMP REGISTRATION.
Administration of Medication Consent
Please fill out this form if MAP will be administering medication to your child during the camp day
Child’s Name: _________________________________________________________________________________
In accordance with Massachusetts State Law, MAP policy on the administration of medication is as follows:
Medication must arrive in the prescription container with the date, dosage, and the doctor’s name.
A parent must sign the medication permission form, writing the purpose of the medication, the date, and
times of administration, and the amount given.
Medication must be handed directly to the camp director, not left in the child’s lunch box or equipment bag.
MAP will not administer the following:
Non-prescription drugs (unless authorized by the parent/guardian and a medication permission form is completed.
Medication is not contained in the prescription package. Single tablets or jarred liquid will not be administered and will therefore be sent home.
Medication in any amount exceeding the dosage indicated on the bottle
If you require more room, please attach a separate sheet
Medicine |
Route (oral, topical, etc) |
Dose |
Time |
Refrigeration |
|
1 |
YN |
||||
2 |
YN |
||||
3 |
YN |
||||
4 |
YN |
Special Instructions: ____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Does your child have any difficulty taking medications? YES NO If Yes, please describe: _________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I hearby authorize MAP to administer the above named medications to my child, in accordance with Board of Health regulations 105 CMR 430.160.
Signed: ___________________________ Print Name: _________________________ Date: _________________ 1
BOARD OF HEALTH REGULATION FOR ADMINISTERING MEDICATION DURING CAMP HOURS
105 CMR 430.160 (A)
Medication prescribed for campers shall be kept in the original containers bearing the pharmacy label, which shows the date of filing, the pharmacy name and address, the filing 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 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 healthcare consultant. Medication prescribed for campers brought from home shall be only administered if it is from the original container, and there is written permission from the parent/guardian.
105 CMR 430.160 (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.
*Health Supervisor - A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross First Aid (or its equivalent) and CPR, has been trained in the administration of medications and is under the professional oversight of a licensed health care professional authorized to administer prescription medications.