Volunteer – Permission to Administer Medication

Please complete this form only if you will carry medication (including an epipen) with you while you’re at work. This form gives permission to other staff members to provide medication in case of emergency. Otherwise, you can skip this form.

Administration of medication will not be provided without this completed and signed form. Staff with a serious health concern are strongly encouraged to have proper identification on them at all times (i.e., Medic Alert Bracelet). It is your responsibility to provide, in advance, medication/supplies for any treatment required in a life-threatening situation. These health concerns include, but are not limited to: severe allergies and anaphylactic shock, severe asthma, seizures and diabetes.

EPIPENS

It is recommended that staff bring (where applicable) two Epipens to camp. We will keep one in the First Aid office and the other should be worn at all times (in a fanny pack) by said staff member.

All medications must be in an original container with a currently dated, accurate pharmacy label.

Name *

First

Last

Email *

Date of Birth (format: May 25, 2005) *

Emergency Contact Name *

First

Last

Emergency Contact - Telephone Number (cell) *

Emergency Contact - What is this person's relationship to you? (ie. mom, husband)

Health concern for which medication is to be given (ie. diabetes, epilepsy) *

Name of medication/emergency injection *

Dosage (ie. 30mg tablet, epipen as provided) *

Expected side effect (if any). Type 'NA' if not applicable *

Under what circumstances should this medication be administered (ie. light-headed, fainting, shortness of breath) *

Note: Our employees are instructed to follow the doctor's or parent's/guardian's instructions explicitly. Persons dispensing medications are not medically trained health care professionals and cannot be held responsible for any conditions that may arise from the administration of the medication to a camper, that are beyond their control.

As a staff member of Camps Canada, I hereby give permission to Camps Canada and its employees to administer the above listed medication prescribed for the staff member noted above.

I certify that the information provided on this form is accurate and complete. By clicking the 'send' button, I acknowledge that I have read, understood and agree to be bound by the terms listed herein.