2021 Summer Camp Parent Handbook - Sarasota County
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2021 Summer Camp Parent Handbook
Parks, Recreation, and Natural Resources
1660 Ringling Blvd., Sarasota, FL 34236
Dear Parents/Guardians,
Sarasota County Parks, Recreation and Natural Resources (PRNR) is proud to offer our 2021 Summer
Camp Programs. Our recreation team has spent many hours planning programs to provide a safe, fun-
filled summer experience. These activities promote teamwork, fairness, environmental awareness, and
self-reliance as well as physical and positive social development.
You and your child(ren) are valuable customers. We can learn from others and we encourage you to
offer comments and suggestions on how we can better our programs and services. Feel free to talk to
our staff or email us at parksonline@scgov.net with suggestions, comments, or concerns.
On behalf of our department, I thank you for choosing Sarasota County PRNR to provide for your
summer camp and recreational needs. Have a safe and enjoyable time!
Yours in Service,
Lauren Kabrick
Lauren Kabrick, CPRP
Recreation and Neighborhood Parks Manager II
Sarasota County Parks, Recreation, and Natural Resources
5500 S. Tamiami Trl., Sarasota, FL
34231
Cell: 941-500-3180
Email: lkabrick@scgov.net
Web: www.scgov.net
Page 2
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent Handbook
MISSION STATEMENT
To provide a premier parks system that enriches our community through participation,
learning and stewardship.
We are committed to providing a Summer Camp that will:
• Ensure a safe environment. All camp staff are vigilant about where their campers are, what they
are doing and the condition of the equipment and physical space.
• Provide a variety of fun and engaging activities. Camp staff are trained to provide a wide range
of games, sports, arts and crafts, field trips and other recreational opportunities to socialize
amongst their peers.
• Communicate regularly. Our staff will maintain open lines of communication and are committed
to keeping parents informed about your child(ren) and their camp experience. Staff will remind
parents about special days, activities, and field trips via emails and/or handouts.
• Take an interest in their child's success. Our staff is encouraged to develop each individual child
and make sure that they offer well planned and activities that build self-esteem, character, and
sportsmanship.
Page 5
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent Handbook
2021 SUMMER IN THE PARKS CAMP LOCATIONS
Camp Locations Are Highlighted
Please see the Summer 2021 Camp Guide for Specialty Camp Locations
SITE PHONE#
PRNR Central Reservations
941-861-7275 Camp Enrollment and Registration
6700 Clark Rd.
Sarasota, FL 34241 Questions or Concerns
Recreation and Neighborhood Parks Office
941-316-1309 General Camp Questions
5550 S. Tamiami Trl.
Sarasota, FL 34231
Bee Ridge Park
4430 S Lockwood Ridge Rd. 941-316-1328 Earlayna Batch – Site Coordinator
Sarasota, FL 34231
Colonial Oaks Park
941-316-1330 Patricia Pritchard – Site Coordinator
5300 Colonial Oaks Blvd.
Sarasota, FL 34232
Laurel Park Recreation Center
509 Collins Rd. 941-486-2753 Miroslava (Mimi) Bolden – Site
Nokomis, FL 34275 Coordinator
Longwood Park Recreation Center
941-316-1383 Elizabeth Jones – Site Coordinator
6050 Longwood Run Blvd.
Sarasota, FL 34243
Woodmere Park Recreation Center
941-486-2780 Jamal Edwards – Site Coordinator
3951 Woodmere Park Blvd.
Venice, FL 34293
Parks, Recreation and Natural
Resources (PRNR)
ADMINISTRATION
PRNR Director:
Nicole Rissler 941-861-5483 nrissler@scgov.net
PRNR Senior Manager
Shawn Yeager 941-539-4925 syeager@scgov.net
Recreation Division
Manager:
James Wormley 941-281-5055 jwormley@scgov.net
Recreation Manager:
Lauren Kabrick 941-500-3180 lkabrick@scgov.net
Supervisor North County:
David France 941- 358-2855 dfrance@scgov.net
Supervisor South County:
Sarah Good 941-500-9128 sgood@scgov.net
Page 6
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent Handbook
GENERAL INFORMATION
The purpose of these guidelines is to provide you with the basic policies and procedures that allow for
safe and organized programs. Guidelines shall be followed at each camp throughout the County. It is
your responsibility as parents/guardians to review this information with your child (or children) so that
all involved understand and agree on camp operations. However, the one thing that remains constant is
our team’s commitment to the health and safety of your children. If you have a sick child please do not
send them to camp in an effort to ensure the health and safety of everyone at camp.
Sarasota County Parks, Recreation and Natural Resources has been working with the Department of
Health, researching, and evaluating the latest guidelines from the Center for Disease Control and
Prevention (CDC) and developing best practices to offer a safe environment for your child(ren) to attend
summer camp. Please take a moment to review this summer’s adaptations and camp guidelines. If you
have any questions, please contact the camp office at 941-861-7275 (PARK).
The following adaptations have been made for the safety of your child(ren) and staff:
✓ Park facilities with summer camp programs will not be open for public use until camps end
in August.
✓ All reservations will be paused for the duration of Summer and Mini Camps at camp
locations to minimize interaction with the public.
✓ Campers will remain in their assigned groups throughout the day. Activities will be
structured to minimize intermingling of
groups.
✓ Performers and educators will follow current
CDC protocols before entering a campsite.
✓ Outdoor activities will be prioritized to
maintain social distancing.
✓ Curb-side drop-off and pick-up will occur at
each camp. ID checks – adults are encouraged
to remain in the vehicle at pick-up to reduce
interaction with staff and other campers.
Please understand that we perform ID checks
to maintain the safety of all our campers.
Frequently staff rotate in/out of check in/out
responsibilities and may be unfamiliar with all
the parents and/or authorized pick-up
individuals for each family. ID checks are the
safest and most effective method of
consistency.
✓ Parent issues will be addressed via phone and
parents will be encouraged to remain in
vehicles and reduce in person interaction with
staff and other campers.
Page 7
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent Handbook
✓ If a child becomes sick, the child must be fever-free (
COST
Summer Camp payments are due in full prior to your child attending the program. The rate of
$98/week includes the following:
✓ Field trips every week.
✓ Professional entertainer each week.
✓ Camp fee includes all field trips and activities.
✓ One camper T-shirt provided with each session enrollment.
✓ Meal service provided as field trip schedule allows.
✓ Staff-to-camper ratio is less than one-to-20.
✓ Camp fee breaks down to $1.96 per hour, $19.60 per day, $98 per week.
✓ Minimum enrollment is required for all programs.
2021 Summer in the Parks Day Camp Program
$294.00 for 3-week camp session
2021 Specialty Camps
Please see the 2021 Camp Guide for the program and fee schedule.
REFUNDS
No refunds for any programs or sessions will be issued after Monday, May 17, 2021.
NSF CHECK FEES
A returned check, for any reason, will be charged the face value of the check plus a service
charge. Service charges are based on the amount of the check, minimum of $25.
RECEIPTS/TAX ID NUMBER
For your records, Sarasota County’s Tax ID number is 59-6000848. Please keep your receipt for tax
purpose.
STAFF
Sarasota County takes pride in our summer camp and strives to hire qualified individuals to serve
you and your family. All staff undergo state and local criminal background checks, a fingerprint
screening, a state sexual predator background check and substance screening. Our staff
encourages open communication to ensure that your child has the best camp experience. Feel free
to contact the staff to discuss any questions or concerns.
ATTIRE
Please provide your child (or children) with the proper attire. Closed-toe shoes are required. Refer
to the field trip schedule and provide sunscreen on the appropriate days. Staff is not permitted to
apply sunscreen. Time will be set aside for children to apply sunscreen. Shirts and hats should be
worn to prevent sunburn.
Page 9
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent Handbook
PERSONAL ITEMS
Campers should not bring any personal items such as
toys, cell phones, games, radios, trading cards,
headphones or money to camp unless approved by staff.
Staff is not responsible for personal items.
LOST AND FOUND
Each camp will maintain a lost and found area at the facility. Please
adhere to the following guidelines:
✓ Label everything your child brings to camp with their full name.
✓ Do not send expensive equipment to camp. (No video games,
electronics, phones, etc.)
✓ Have your child leave all toys, games, cards, etc. at home unless
otherwise notified.
✓ We are not responsible for the loss or damage of items that your
child may bring to camp.
✓ Lost and Found items not claimed within a reasonable amount of
time will be donated to charity.
LATE FEES
Camp hours are 7:30 a.m.-5:30 p.m. A late fee will be charged when campers are picked up late from the
camp programs. This policy is strictly enforced, and your child will not be allowed to return to camp
until the late fees are paid.
✓ $10 will be charged for the first 15 minutes.
✓ $1 will be assessed for each minute after the first 15 minutes.
SUMMER FOOD PROGRAM (Breakfast & Lunch)
On-site breakfast and lunch are provided through the Sarasota District Schools Food and Nutrition
Services Summer Break Spot program. A snack time is scheduled each day and we encourage you to
pack a healthy snack for your child. We do not refrigerate lunches or snacks; please keep this in mind
when preparing them. A water dispenser will be available for campers to refill their personal water
container; campers will not use the park water fountain. Please label your child’s lunch box or cooler as
well as all other personal items.
Page 10
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent Handbook
DROP OFF\PICK-UP PROCEDURES
PRNR will offer curbside drop-off from 7:30-8:30 a.m./ pick-up from 4:00-5:30 p.m. For late drop-off
and early pick-up, park and call the park office for camper assistance.
✓ If you have a sick camper, please keep them home to ensure the health and safety of everyone at
camp.
✓ Please stay in the car line.
✓ A car tag will be provided to each person
registered as authorized to pick up a
camper. Photo ID is required.
Please understand that we perform ID
checks to maintain the safety of all our
campers. Frequently staff rotate in/out of
check in/out responsibilities and may be
unfamiliar with all the parents and/or
authorized pick-up individuals for each
family. ID checks are the safest and most
effective method of consistency.
✓ You may have chosen to have your child walk or bike home. If you chose this option, your child can sign
themselves out at the close of camp and staff will release them.
Page 11
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent Handbook
HEALTH RELATED MEDICAL CONCERNS
✓ All camp participants must be toilet trained and be able to use toilet facilities independently.
✓ If a child becomes ill while at camp, he/she will be isolated from other campers, supervised by
staff, parents will be called, and the camper must be picked up immediately to minimize risk to
other campers and staff.
✓ Campers who have a contagious illness will need to stay home until they are symptom-free
without medication for 24 hours.
✓ If a child attending camp is diagnosed with a contagious illness, parents will be notified by letter
so you may watch your child for similar symptoms.
✓ If your child has lice, you will need to keep them at home until they are lice-free.
MEDICATION POLICY and PROCEEDURE
Campers May Not Keep Medication(s) in their backpacks, lunch boxes, or on their person at any
time. Medication(s) must be kept in a locked container, onsite, in the Camp Office.
Sarasota County Parks, Recreation, and Natural Resources Day Camp Program will keep on file the following
information:
Prescribed inhalers or Epi-pens or other prescribed medications with parent’s consent; and a doctor’s signature.
Medication(s) will be stored onsite, in the camp office, in a locked box or container. Staff do not have the ability
to keep medication cold – therefore if a medication requires refrigeration – the parent should provide an
insulated bag with effective cooling accessories (such as ice packs).
Authorization forms for each medication, which require a parent’s and doctor’s signature, are required. Sarasota
County Parks, Recreation and Natural Resources Summer Camp Staff and Coordinators will make all necessary
efforts to ensure the timely and proper self-administration of camper medication(s) – however, are not responsible
for lost, stolen, or spoiled medications or improper or untimely self-administration. It is the parent’s responsibility
to inform and instruct the camper who must self-administer their own medication how to do so properly prior to
the first day of camp.
Page 12
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent HandbookParent Responsibilities
It is the parent’s responsibility to inform the Camp Supervisor upon arrival, on the 1st day the camper attends
the program, that their child has a prescribed inhaler, epi-pen, or other prescribed medication. The medication
must be provided to the Camp Supervisor to be inaccessible to other children. Medication forms are required to
be signed by both the parent and physician before the program starts. They must include:
• The child’s name, address, and birth date.
• The drug name and prescribed dose.
• The method of administration (oral, topical, epi-pen, etc.).
• The time to be self-administered.
• The side effects.
• The prescriber’s name and address.
• Medications must be in their original container and clearly labeled.
Staff Responsibilities
Medication will be self-administered by camper, but under supervision by a camp staff member. Staff will keep
accurate documentation of all medications administered by completing the Medication Log, which will be kept
in the Program Coordinator’s Office. Individual administration records shall include:
• The date and time the medication was administered.
• The dose that was administered.
• Any comments
• Parents shall be notified of any administration errors by telephone. The error will
be documented in the child’s camp record.
SUNSCREEN
Camp staff recommend that participants wear sunscreen each day. It is the parent/guardian’s
responsibility to provide sunscreen for their child. We do not apply sunscreen to the child, nor can
we assist the child in their application. We do, however, take sunscreen breaks to reapply
throughout the day. Our goal is to protect each child and prevent any occurrence of sunburn.
Page 13
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent HandbookFIRST AID
In the event of an injury, staff will take necessary steps to keep children calm. Staff will seek emergency
medical care as warranted. The following actions may include but are not limited to:
• Provide immediate first aid.
• Attempt to contact a parent or guardian.
• If a parent or guardian cannot be reached, we will attempt to contact others listed on your
registration forms.
• In the case of serious injury, appropriate emergency medical assistance will be contacted (911
will be called).
• If we are unable to reach you or the authorized person on your medical release form, the
emergency EMT staff will transport the child to the nearest hospital.
When emergency medical staff warrants that the child be taken to the nearest hospital, transport
fees will be the responsibility of the parents or legal guardian. We will contact you and inform you
of the EMS staff recommendation. A PRNR staff member will remain with the child until the
parents, or another authorized adult arrives. Sarasota County Parks, Recreation and Natural
Resources staff may not transport program participants.
INDOOR/OUTDOOR ACTIVITIES and CAMPER GROUPS
Campers participate in various activities, both indoor and outdoor. Campers are grouped in similar age
groups. We cannot take special requests for grouping campers together.
PROGRAM ROTATIONS
The daily activities will be structured around a rotation schedule utilizing various areas of the camp
facilities. These rotations will be daily. We ask that all campers bring a water bottle to camp to help
keep them hydrated throughout the day. Campers are
encouraged to participate in the many exciting
activities and events that are provided at Summer Camp.
CAMP RULES
Be respectful toward other campers and camp staff
Follow directions
No fighting
No foul language
No phone use
No sexually suggestive language or behavior
No smoking or drug use
No stealing
No teasing other campers
No weapons of any kind
No bullying of any kind will be tolerated
Page 14
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent HandbookDISCIPLINE PROCEDURE(S)
Should a disciplinary problem arise, parents/guardians will be contacted if the problem affects the safety
and well-being of another camper or staff member, or if the problem cannot be resolved after fair
warning.
A Three-Strike System for misbehavior and continued misbehavior is used in all camp programs:
✓ First Strike: warning
✓ Second Strike: suspension from the program or removal from the next field trip
✓ Third Strike: permanent removal from summer camp (NO refunds will be given.)
Suspension or expulsion is possible regardless of strikes or without warning if:
✓ A child deliberately harms another child or staff member.
✓ A child deliberately or willfully destroys the property of others. Damage to property will be paid
for by parents.
ON-SITE PERFORMERS
Professional performers are scheduled to entertain campers in small groups. Performers will have their
temperature checked and will be asked health screening questions prior to any interaction with campers.
Performers are strongly encouraged to wear face masks or shields. PRNR will offer performers a face
shield if they do not provide their own.
FIELD TRIPS
The camp program offers a variety of field trips. All children shall participate in these trips, and the camp
facility may be vacated. Please have your child (or children) at camp by
8:30 a.m. to participate. Please note the following:
ALL Campers and Staff are required to wear face
coverings while on their buses to and from off-site field
trips per Sarasota County Public School rules.
✓ Participants must be able to transfer on and off standard school
buses with minimal assistance.
✓ Registration fees include the cost of all field trips. Field trip fees
cannot be refunded. Refer to the field trip schedule for locations.
✓ Field trips are subject to change without notice. Whenever
possible, you will be notified of any changes.
✓ A field trip and general release must be signed by a parent or guardian at time of registration. This
will cover all camp programs unless additional permission slips are required by field trip vendors.
✓ Announcements will be made daily at all camps, so ask your children where they will be going and
refer to the schedule. Provide your children with the proper attire, sunscreen, lunch and beverages.
NO GLASS CONTAINERS. Label personal items with your children’s names.
✓ We encourage parents to be frugal if sending spending money with campers. Spending money is
not necessary. Staff is not responsible for a camper’s personal money.
✓ For late arrivals or early dismissals, you will be responsible for getting your children to or from the
field trip site. Children must be signed in or out with camp staff at the field trip location.
Page 15
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent HandbookCUSTODY MATTERS
It is Sarasota County PRNR’s intent to meet the needs of the children, especially when their
parents/guardians are experiencing a difficult situation such as divorce, separation, or remarriage.
However, the center cannot restrict the non-custodial parent from visiting the child, reviewing the child’s
records, or picking the child up unless the center has been provided with current legal documents restricting
the parent from having access to the child(ren). Copies of the court documents will be kept in the child’s
file.
CHANGE OF EMERGENCY INFORMATION
It is important that Sarasota County Parks, Recreation and Natural Resources maintains current and
accurate records on each child so that parents can be contacted in case of an emergency. This information
includes address, phone numbers, email and names of individuals authorized to pick up your child(ren). It
is extremely important to the safety of your child(ren) that we be informed of changes. It is the
responsibility of the parent/guardian to make any necessary updates if changes occur.
AMERICAN WITH DISABILITIES ACT
Sarasota County Parks, Recreation and Natural Resources strives to make its programs, services, and activities
accessible to qualified individuals with disabilities. The County will make reasonable modifications to the
programs, services, and activities within the department to ensure accessibility to such individuals. View the
complete policy at www.scgov.net/ADA.
REASONABLE ACCOMMODATION
Children of all abilities are invited to enroll in our summer camp programs. During registration, be sure to indicate
that an accommodation is necessary for your child so we may contact you prior to camp to discuss reasonable
accommodation.
BULLYING
Bullying is unwanted, aggressive behavior among school aged
children that involves a real or perceived power imbalance.
The behavior is repeated, or has the potential to be repeated,
over time. Both kids who are bullied and who bully others may
have serious, lasting problems.
In order to be considered bullying, the behavior must be aggressive
and include:
An Imbalance of Power: Kids who bully use their power—such
as physical strength, access to embarrassing information, or
popularity—to control or harm others. Power imbalances can
change over time and in different situations, even if they
involve the same people.
Repetition: Bullying behaviors happen more than once or have the potential to happen more than once.
Bullying includes actions such as making threats, spreading rumors, attacking someone physically or verbally,
and excluding someone from a group on purpose.
Page 16
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent HandbookWe are committed to providing a caring, friendly, and safe environment for all of our camp participants
that allows them to interact in a relaxed and secure environment. The Sarasota County Parks,
Recreation and Natural Resources Camp Program will not tolerate bullying behavior in our camps. If
bullying does occur, all campers should be able to tell staff and know that incidents will be dealt with
promptly and effectively. Anyone who knows that bullying is occurring is expected to tell a staff
member.
We are committed to addressing concerns that fall under bullying immediately and fairly, informing
parents about bullying and disciplinary policies and stressing to all camp participants the importance of
choosing respect when interacting with one another.
COMMUNICATION
Parents/Guardians must inform the staff when:
✓ Household contact information should be updated (i.e. change in phone #, e-mail, address,
emergency contact, etc.)
✓ Someone other than those listed on your child’s registration will be picking up your child.
This information must be in writing and the designee will be asked to show valid
identification.
✓ Your child cannot be picked up on time or your child will be late.
✓ If your child or member of the household is ill.
Parents/Guardians will be notified when:
✓ Your child is injured or ill.
✓ Your child is having disciplinary issues.
✓ Your child has any other issue or incident in camp that you need to be notified and informed
of.
Please communicate any questions, comments, or concerns you may have to parks staff. Keeping
open communication between parents/guardians and staff is key to the successful after school
program.
EVALUATIONS
Evaluations will be issued for each of the “Summer in the Parks” programs. Your comments and
concerns are important to us. Please take time to fill out the evaluation when it is sent out, your feedback
means a great deal to us.
Summer in the Parks Evaluations
6700 Clark Road
Sarasota, FL 34241
Page 17
Sarasota County Parks, Recreation and Natural Resources Summer Camp Parent HandbookSUMMER CAMP PROGRAM – Self-Administration and Storage of Medication Policy
Campers May Not Keep Medication(s) in their backpacks, lunch boxes, or on their person at any
time. Medication(s) must be kept in a locked container, onsite, in the Camp Office.
Sarasota County Parks, Recreation, and Natural Resources Day Camp Program will keep on file the following
information:
Prescribed inhalers or Epi-pens or other prescribed medications with parent’s consent; and a doctor’s signature.
Medication(s) will be stored onsite, in the camp office, in a locked box or container. Staff do not have the ability
to keep medication cold – therefore if a medication requires refrigeration – the parent should provide an
insulated bag with effective cooling accessories (such as ice packs).
Authorization forms for each medication, which require a parent’s and doctor’s signature, are required. Sarasota
County Parks, Recreation and Natural Resources Summer Camp Staff and Coordinators will make all necessary
efforts to ensure the timely and proper self-administration of camper medication(s) – however, are not responsible
for lost, stolen, or spoiled medications or improper or untimely self-administration. It is the parent’s responsibility
to inform and instruct the camper who must self-administer their own medication how to do so properly prior to
the first day of camp.
Parent Responsibilities
It is the parent’s responsibility to inform the Camp Supervisor upon arrival, on the 1st day the camper attends the
program, that their child has a prescribed inhaler, epi-pen, or other prescribed medication. The medication must
be provided to the Camp Supervisor to be inaccessible to other children. Medication forms are required to be
signed by both the parent and physician before the program starts. They must include:
• The child’s name, address, and birth date.
• The drug name and prescribed dose.
• The method of administration (oral, topical, epi-pen, etc.).
• The time to be self-administered.
• The side effects.
• The prescriber’s name and address.
• Medications must be in their original container and clearly labeled.
Staff Responsibilities
Medication will be self-administered by camper, but under supervision by a camp staff member. Staff will keep
accurate documentation of all medications administered by completing the Medication Log, which will be kept in
the Program Coordinator’s Office. Individual administration records shall include:
• The date and time the medication was administered.
• The dose that was administered.
• Any comments
• Parents shall be notified of any administration errors by telephone. The error will be
documented in the child’s camp record.
By singing below I acknowledge that I have read and fully understand the Sarasota County Parks,
Recreation, and Natural Resources Camp Medication Storage Policy and Procedure.
Parent Signature ______________________________________ Date_________________________Prescription Medication Authorization Form
Medical Release - Self-Administration
Program Name: Sarasota County Parks, Recreation, and Natural Resources Summer Camp Program
has been instructed in the use of
(Camper Name)
. We,
(Medication) (Physician)
and request that this camper
(Parent/Guardian)
be permitted to keep it locked in the Camp Office and self-administer this prescription medication,
because we consider they/them responsible for its administration. We authorize him/her to do so.
He/she has been instructed in and understands the purpose and appropriate method, frequency,
dosage, and use of the medication.
We, the undersigned, release the Sarasota County Parks, Recreation, and Natural Resources Camp
Program and its employees of all liability resulting from this camper’s self-administration of his/her
medication. We acknowledge that, from this day forward, the Camp Program assumes no supervisory
responsibility over the camper’s self- administration of the above-listed medication(s).
Physician Signature Date
Parent/Guardian Signature Date
Child’s Name Date of BirthPrescription Medication Authorization Form
Program Name: Sarasota County Parks, Recreation and Natural Resources Summer Day Camp Program
Sarasota County Parks, Recreation and Natural Resources requires this form to be completed for all
campers who are currently taking prescription medication during Camp hours. Any change in
medication, dose, or frequency will require a new form from the physician. The following information
is to be completed by a physician only.
Student Name Date of Birth / /
Drug Name Dosage Time/Frequency Method
Side Effects:
Medication to be administered from / / to / /
M.D. Signature Date / /
Print Name
DEA # if drug is a controlled substance
M.D. Address
M.D. Telephone # FaxYou can also read
