BIG HORN MOUNTAIN CAMP

For the Deaf and Hard of Hearing

 

AUTHORIZATION FOR ADMINISTRATION OF MEDICATION AND RELEASE OF LIABILITY

The undersigned, in accordance with Wyoming Statute 33-21-154 hereby designate the Big Horn Mountain Camp (BHMC) staff members to administer the following medication to:

NAME OF CHILD: ______________________________

 

DATE OF BIRTH:_________

 

NAME OF MEDICATION: _____________________________________________

 

INSTRUCTION FOR ADMINISTRATION: ________________________________________________________________________

 

A.M.__________________          P.M.______________________

 

Possible side effects are: _____________________________________________

 

NAME & PHONE NUMBER OF PRESCRIBING PHYSICIAN: _____________________________________       __________________________

 

In consideration of staff personnel administering such medicine, the undersigned hereby releases said camp and its personnel from all claims, demands and liabilities, direct and indirect, which may result or accrue by reason of the administration of such medicine, the failure to administer it, or the improper administration thereof.

 

I have read and understand this authorization. I hereby give my permission for BHMC staff members to administer the above prescription at camp. I understand that it is my responsibility to furnish this medication in the original container with recommended dosage on the label.

 

Dated this _______________________day of ________________, 20_________.

 

_____________________________________________

Parent or Legal Guardian

 

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Write any other instructions to be aware of on the back of this form.