PARTICIPANTNAME:___

MEDICATION ADMINISTRATION AUTHORIZATION

I authorize designated camp staff to administer prescription and/or over-the-counter medications to my child as documented on the Medication Administration Form.

• I understand that:
• Medications must be provided in original containers
• Instructions must be clearly labeled
• Medication will be administered by authorized personnel only

□ I GIVE permission

□ I DO NOT GIVE permission

Parent/Guardian Initials: ___

EMERGENCY MEDICAL TREATMENT AUTHORIZATION

I authorize Kentucky State University staff and representatives to seek and obtain medical care for my child in the event of illness or injury when I cannot be reached.

• This includes authorization for:
• Emergency medical treatment
• Hospitalization
• Necessary medical procedures as determined by licensed medical personnel I understand that I am financially responsible for any medical services provided.

□ I GIVE permission

□ I DO NOT GIVE permission

Parent/Guardian Initials: ___

HEALTH INSURANCE ACKNOWLEDGEMENT

• I understand that Kentucky State University does not provide medical insurance coverage for participants. I agree that:
• I am responsible for all medical expenses incurred
• I have provided current insurance information (if applicable)

□ I ACKNOWLEDGE AND AGREE

Parent/Guardian Initials: ___