Medical Form MEDICATION ADMINISTRATION FORM 4341 FM 356 | Trinity, TX 75862 | 936-594-5011 | TrinityPines.org 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 As the parent or legal guardian of the above-named child, I give my permission to the Trinity Pines Medical Staff to administer as prescribed by law the medication listed below to my child. Parent/Guardian Signature: Date: Daytime Phone #: Evening Phone #: As an Adult Camper/Sponsor/Staff, I give my permission to the Trinity Pines Medical Staff to administer as prescribed by law the medication listed below to me during my stay at Trinity Pines Conference Center. Adult Camper/Sponsor/Staff Signature: Date: 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 × + Add Medication 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. Submit Download/Print PDF
