Required fields are marked with asterisks (*)

Authorization for administration of medicine

By completing this form you are consenting to allow the City's Inclusion Services team to administer medication to your camper.

*Only fill out this form if your child is taking medication during the camp day.

Administration of medication during camp programs is provided by trained staff and includes cueing (such as placing medication in the camper’s hand and/or prompting through a verbal or visual cue), providing a reminder to a camper at an identified time to take their medication, and administering medications in an emergency.

Staff are only able to assist with administration of the following medications:

Routine oral medications in the form of pills
Emergency medications including Epi-pens^TM, inhalers and oral pills to stop a seizure

Staff are unable to administer medications such as:

Medications in forms such as liquids, creams, drops, sprays, patches or injectables (excluding Epi-pens^TM)
Over-the-counter medications such as Tylenol, Advil, Gravol, etc.
PRN or as-needed medications with the exception of emergency medications listed above
Vitamins, supplements, herbal medications
Antibiotics in any form
Controlled substances such as opioids or narcotics

When an individual is attending a program with a private support worker, the private support worker is responsible for all medication administration to the individual.

If you have questions about what medications staff can assist with, please contact inclusion@waterloo.ca.

Step 1 - Add your child's information

Your name (First and Last name):

Phone number (in case of emergency):

Your email address:

Participant name (First and Last name):

Upload a photo of the participant (head only), 2MB or less

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Indicate program your participant is attending

Fun Centres - AMCC

Fun Centres - RIM Park (4-6)

Fun Centres - RIM Park (5-7)

Fun Centres - WMRC

Summer Adventure camp

Variety camp

Winter break camp

March break camp

Other

Step 2 - Add medicine information

I authorize the administration of the following medication to my child by City of Waterloo camp staff:

This medication is a:

Routine oral pill given at the same time each day

Emergency medication given only when certain symptoms are present

Please provide instructions for the administration of medication including quantity, route (i.e. oral, under tongue), (dose/strength) and any specific instructions:

Authorization is effective for the following dates:

Side Effects: Stop medication if the following reaction(s) are observed:

Staff will work closely with you to ensure medication is stored appropriately to support the needs of your participant while ensuring the safety of all participants. Please select how you recommend the medication be stored:

Participant will wear a waist pouch (for emergency medications only)

Staff will carry medication (for emergency medications only)

Staff will securely collect, store and lock up medication (all other medications)

Add additional medication(s) Remove

Step 3 - Authorization and signature

I agree to the following (check all):

Only send medications prescribed by a physician or nurse practitioner

Send all medications in their original container with the participant’s name on it

Only send enough medication for the day

Drop off/pick up medication/containers at the beginning/end of each day

Typed parent/guardian signature:

Under the authority of the Municipality Act, 2001, S.O., Personal Information, including Personal Health Information, will be collected for the administration of the camp program. As part of the camp program, participants' health information collected will ensure safe and supportive programming for each participant. If you have any questions regarding the collection and handling of this personal information, please contact Inclusion Services at inclusion@waterloo.ca, 519-886-2310 x 27249 or 100 Regina Street South, Waterloo, Ontario, N2J 4A8.

Forms

Authorization for administration of medicine

Step 1 - Add your child's information

Step 2 - Add medicine information

Step 3 - Authorization and signature