Authorization for Administration of PRN Medication 2024
Form has to accompany Medication and signed
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Email *
Participants Name: *
DOB: *
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IN CASE OF EMERGENCY:
contact Person, Relationship, Cell-Work-Home Phone  *
REQUEST AND APPROVAL OF PARENT/GUARDIAN:
I hereby request and give permission for medication prescribed herein to be administered to my participant who is named above for the duration indicated by the Physician.. I will provide the medication in the original container.
Note: It is the parent/guardian responsibility to notify Active Lives Canada/Zachary's Camp of any changes in the prescribed  medication or the administration of the medication. This authorization will expire on the date indicated by the Physician.
I release Active Lives Canada/Zachary's Camp, its employees and agents from any liability for loss, damage or injury, howsoever caused, to my child's person or property arising out of administrating , or failure to administer the procedure as provided herein
Signature and Date:
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Please type specific Symptoms necessitating the administration of PRN Medication:
Statement of Physician:
 *
Name/Type of medicine: *
Dosage/amount to be given *
Frequency/interval: Instructions for administration *
Medical Practitioners Name and Phone Number: Printed and signed and dated *
VALIDATION PROCEDURE PRIOR TO ADMINISTRATION OF MEDICATION: 
Before a PRN medication is administered to a student, designated staff must validate when the medication was last given to determine that the administration time complies with authorized frequency of administration. 
This determination may be accomplished by taking one or all of the following actions
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Required
Referring to the Individual Participant Log of Prescription Medication Administration for documentation of
the time the last dose was administered;
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Required
Noting the time of the request and validating that the participant has been in attendance at camp for the
length of time of the authorized frequency for PRN medication administration;
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Required
Calling the parent/guardian to validate when the medication was last given at home when the participant
has been in attendance at camp less than the length of time of the authorized frequency for the
administration of the PRN medication;
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Required
Before administering PRN medications, the staff member must validate the symptoms being
experienced by the participant as the symptoms identified by prescribing physician in allowing for the
administration of the medication;
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Required
When a PRN medication is administered, the information recorded on the Individual Participant Log of
Prescription Medication Administration includes the symptoms for which the PRN medication was
administered.
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Required
Additional Information: *
STATEMENT OF PERON ADMINISTERING THE MEDICATION:I have agreed to administer the medication as herein requested by parent/guardian and as prescribed by Physician. I will maintain a log to such administration: Signature (printed and signed) of person administering medication and date *
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