Permission to Dispense Medication

    Please complete the form in full.

    Instructions

    Please complete this form for all medication(s) your child will be taking as needed at camp. This form must accompany your child to camp only if he/she is taking any medication. Please read the following information related to the “Medication Policy” at the Kenilworth Park District Summer Camp. Your signature below indicates that all information provided on this form is correct and that you understand the Kenilworth Park District Summer Camp medication policy. Medication will not be dispensed for any camper without a completed and signed “Permission to Dispense Medication” form.
    All medications (over the counter and/or prescription) must be submitted prior to camp participation for any camp participant. All medication must be in the ORIGINAL CONTAINER with the campers name printed on the bottle. Zip-Lock bags, pillboxes, non-original medicine bottles, or any other type of container besides the original will not be accepted. The dosage instructions listed on the bottle must be followed unless there is a written note from the physician of the camp participant.

    Medication Name

    When/Time of Day

    List all medications along with any special instructions.
    As NeededBreakfastLunchDinnerBedtime
      Add/remove a medication:

    Waiver and Release of Claims

    I recognize and acknowledge that there are certain risks of physical injury in connection with the administering of medication to my minor child. Such risks include, but are not limited to, failing to properly administer the medication, failing to observe side effects, failing to assess and/or recognize an adverse reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to summon emergency medical services.
    In consideration of the Kenilworth Park District administering medication to my minor child, I do hereby fully release or discharge the Kenilworth Park District, and its officer, agents, volunteers and employees from any and all claims from injuries, damages and losses I or my minor child may have (or accrue to me or my minor child), and arising out of, connected with, incidental to, or in any way associated with the administering of medication.
    I have read the waiver and release of all claims. In the event of an emergency and that a parent or designated responsible adult cannot be reached, I authorize the Kenilworth Park District to send my child (properly accompanied) to the nearest hospital facility for emergency medical treatment.
    Optional: Does your child/ward have any physical, psychological, or medical conditions which you feel the Kenilworth Park District should be aware of prior to the start of camp?
    If Yes, please provide additional details:
    I agree to all stated above
    [honeypot surname class:surname]