Medication Administration
Trinity Pines Conference Center | 4341 FM 356 Trinity, TX | 936-594-5011 | TrinityPines.org
Group:
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Camper/Adult Information
Please fill out this form ONLY if you or your child is bringing ANY kind of medication to camp.
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 #:
Allergies & Medical Notes
Allergies (food, medications, insect stings, etc.):
Any pertinent medical history the camp medic needs to know to treat patient accordingly:
I give permission for over-the-counter medication (per camp policy).
Comments / suggestions:
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 the patient’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
Dosage
(amount to be given)
Frequency
(B - Breakfast, L - Lunch, S - Supper, BT - Bedtime, PRN - As Needed)
Purpose
Comments or Special Instructions
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+ Add Medication
Finalize & Submit
Please review your information before submitting.
After you submit, you will be able to print or save a copy for your records.
I confirm that all information provided is accurate.
Submit
