Medical Release Form

Afterschool/Camp Staff will administer only those medications brought to Afterschool or Camp in their original containers and accompanied by a signed authorization form from the parent or legal guardian. If medication needs to be cut in half, it must be done by the parent prior to bringing it to Afterschool or Camp.

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

If yes, list medications:

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.

SIGNATURE OF PARENT/GUARDIAN

Date

Emergency Contact(s)

Name

Phone

Name

Phone

Name

Phone

Verification Code

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