Athens YMCA

Child’s Name*

Attending Weeks (For Summer Camp)
1 2 3 4 5 6 7 8 9 10

Is the camper allergic to any medications (prescription or non-prescription)?
Yes No

Name of medication being administered

Dosage

Frequency/Time(s):

Prescribing Physician

Medications will be administered according to the directions listed above. I understand that the Athens YMCA, its Directors and employees are not liable for adverse effects or injury due to administering (or not administering) the above listed medications.

Emergency Contact(s)

Verification Code

Reload Image

Medical Release Form

Emergency Contact(s)

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