Parents - please fill out
and bring with you to camp.
This form MUST be filled out and signed by your physician in
order for the camp nurse to administer any needed medications (both
prescription and non-prescription such as aspirin, Tylenol, allergy medication,
etc.) all prescription drugs MUST be carried in the container in which they
were issued (with medical orders camper’s name and physician’s name intact),
and given to the camp nurse. Send ample supplies. List below all medications
your child needs to be given while at camp.
Camper’s Name Date ______________________________
Name of
medication(s)
_____________________________________________________________________________________________
Time(s) to be taken
_____________________________________________________________________________________________
Amount to be taken
_____________________________________________________________________________________________
The camp medical
staff has my permission to administer the above medication(s).
Parent or Guardian
Signature Date
______________________________
Physician’s Signature Date ______________________________