Trinity Pines Medical Form

MEDICATION ADMINISTRATION FORM

Trinity Pines Conference Center

Camper/Adult Information

Name: Birth Date: Age: Sex:

Male Female

Church Name: Church City & State:

Permission & Signatures

I am a parent or legal guardian (for minors) I am an adult camper/sponsor/staff

Medication Details

All medications must be accompanied by this authorization form and given to the church contact person who will be responsible for bringing all medication and forms to the TPCC office for review by our Medical Staff.
Place all medications in a large Ziploc bag with your child’s name and church name.
Prescriptions must be in the original container with the camper’s name and the current dosage.
No medication will be given unless they are in original containers per Texas Department of State Health Services.
If your child/youth requires an asthma inhaler or antidote for insect bites or allergies (prescribed by doctor), have them bring at least two (2) to camp. One will be kept by camper, one given to Medical Staff.
TPCC staff request that you do not send over-the-counter medications (Tylenol, Ibuprofen, Benadryl, etc). These are provided by TPCC.

Medication Name	Form (tablet, capsule, liquid, inhaler)	Dosage (amount to be given)	Frequency (how often)	Purpose	Comments or Special Instructions

Finalize & Submit

Please review your information before submitting.
After you submit, you can download or print your completed form.

I have reviewed the above and certify that the information is accurate.