Medication Authorization Form

Camper's Name *

First

Last

Phone

Medication #1 *

Please list medication, dosage & time of day that it should be given, in the space provided below.

Medication #2

Please list medication, dosage & time of day that it should be given, in the space provided below.

Medication #3

Please list medication, dosage & time of day that it should be given, in the space provided below.

Parent's Name *

First

Last

Signature *

I authorize Park Avenue Gymnastics to administer the medication(s) listed above to my child.