School/Camp Medication Form
Permission to administer medication at school or camp. Please allow at least 24 hours for requests to be processed.
Form Name
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Parent / Legal Guardian Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Office
*
Camillus
Liverpool
Prescription Info
Name of Medication
*
Dosage
*
Frequency Taken
*
Time Medication is to be Taken at School/Camp
*
Time of Day
Condition for which Medication is Given
*
Medical Condition
Form Receipt
Where shall we send the School/Camp Medication Form?
*
Mail it to my home
Fax it to me
Fax Number
*
Fax Number
Who should receive the Fax?
*
Please verify that you are human
*
Submit
Should be Empty: