Outdoor Adventure Camp Emergency Medical Authorization And ...

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Date and Time of Dosage Dosage Amount Signature of Designated Person Administering Medication<br />

This form must be used by child care centers and type A homes to meet the requirement of rules 5101:2-12-31 and 51-1:2-13-31.<br />

JFS 01217 (Rev. 9/2005) Page 2 of 2

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Outdoor Adventure Camps 2013 - Nature Center at Shaker Lakes

Date and Time of Dosage Dosage Amount Signature of Designated Person Administering Medication This form must be used by child care centers and type A homes to meet the requirement of rules 5101:2-12-31 and 51-1:2-13-31. JFS 01217 (Rev. 9/2005) Page 2 of 2

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Outdoor Adventure Camp Emergency Medical Authorization And ...

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