Camillus: (315) 487-1541
Liverpool: (315) 652-1070

School/Camp Medication Form

Permission to administer medication at school or camp


Please be sure to complete this entire form to ensure proper processing of your request, then click on the Submit button.

Please fill out completely.

Patient Information

Patient's Name (required)

Patient's Birthdate

Parent's Name


Phone Number

Primary Office *REQUIRED

Prescription Information

Name of medication


Frequency taken

Time medication is to be taken at school

Condition for which medication is to be given

Form Receipt

Where would you like us to send this immunization record?
Mail to my homeFax to:

  • Home - Fax: Attn:
  • Work - Fax: Attn:

(Answering this tells the system you aren't a spam robot)

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