* 1. What is your child's name?

The child’s parent/legal guardian gives permission to Big Apple Day Program (BADP) to dispense
medication(s) as listed below. The parent/guardian will provide the medication to BADP staff each day in
clearly labeled containers.

* 2. Please list the medications for our nurse to dispense at camp?

* 3. Please list any other medications that we should be aware of?

* 4. Please list any allergies or medical issues for us to be aware of? And any interventions recommended?

* 5. Parent/guardian signature:

* 6. Date: