Medication Permissions Form

Camper Name*
First Last
Lake Geneva Adventures staff will maintain possession of approved medications at all times to keep them secure. Campers may take authorized medication when in program if all requirements are met.
Which camp date(s) are you enrolled in?*
- July 22-23, Team Challenges
- July 29-30, Camp-tastic
- August 5-6, Navigating the Wild
Medication Type*
- This is an over the counter medication in its original package, unexpired and is age appropriate for the camper.
- This is a prescription medication in its original package with proof of prescription to the camper.
Medication Requirements: Over the counter medications must be in the original container, age appropriate for the camper and unexpired. Prescription medications must be in the original container, unexpired and with the pharmacy label stating the camper’s name and the medication dosage. All medications dosage will only be delivered in the designated amounts and times according to the container.
For prescription medication, provide a prescription number.
Reason for Administration*
Type of Medication*
Dosage*
Medication Expiration Date*
Method of Administration*
When to Administer Medication*
Side Effects to Monitor*
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