Microsoft word - campermed sheet

Our Camp infirmary is well stocked with medications most commonly used/needed (as listed on stockmedication sheet, other side). If you choose to send a prescription or non-prescription (over thecounter) drug to camp with your child, for EACH medication you need to complete this form andhave it signed by the prescribing physician.
Please copy this form for each drug you want dispensed Authorized
prescriber or dentist’s order: Date _____/_____/______

Name of Child ___________________________________Date of birth ___/____/___Street Address __________________________City/Town ____________ State______Condition for which drug is being administrated during camp DRUG: Name of drug, dose and method of administration Times of Administration: __,___,___ Medications shall be administered from__/__/__ - ___/___/___Relevant side effects to be observed, if any _____________________________ If there are any side effects, plan for management Is this is a controlled drug? ____________________________________Allergies, reaction to, or negative interaction with food or drugs? If YES, list The authorized prescriber’s or dentist’s name ________________ Phone ( ) Signature of prescribing physician _________________________________ Authorization by Parent/Guardian for the administration of the above medication:Date: I hereby request that the above medication, ordered by the authorized doctor/dentist for my child beadministered by the nurse or by camp personnel with current Medication Administration Training.
I understand that I must supply Hidden Valley Equestrian Center, Inc. CAMP with the
prescribed medication in the original container dispended and properly labeled by an
authorized prescribed, dentist or pharmacist. Over the counter medication shall be in the
original container labeled by the parent with the child’s name. Drugs must not have passed the
expiration date.
I understand that this medication will be destroyed if it is not picked up within one (1) week
following the end of my child’s camp stay.
Name of Parent/Guardian _____________________________________________
Signature of Parent/Guardian__________________________________________
Relationship to Child ____________________ Street Address __________________City/Town _____________________ State______ Zip Code______ Phone FOR CONTROLLED DRUGS ONLY –TO BE COMPLETED AT CHECK
IN Date______ Number of tablets received: _______ Parent’s initials _____ RN initials _____
This section is to be completed by parent/guardian This infirmary at Hidden Valley Equestrian Center, Inc. Camp stocks the following over-the-countermedication and prescription medications. They are administered by a registered nurse or certifiedmedication administrator. It is not necessary to bring any of these mediations to camp unless your childreceives them routinely. Draw a line through and initial any medications you DO NOT want your childto receive.
Aurodri ear dropsBacitracinBenadryl TabletsBenadryl elixirBenadryl cream/spray _______________BengayCalamineCaladrylCloraseptic throat spray _______________DimetappEpipen injection for SEVERE, LIFE-THREATING allergic reactionHydrocortisone cream ______________Ibuprofen (Advil or Motrin) ______________ Imodium ADLotrmin AFMaaloxMilk of MagnesiaMylanta Neural borate rinsePaste of Adolf’s meat tenderizer-unseasoned _______________Erythromycin antibiotic eye ointment_______________Rhuligel RobitussinRobitussin DMSudafedTinactin creamTobrex eye dropsTylenol I hereby give permission to Hidden Valley Equestrian Center, Inc. health care personnel to administer any ofthe above medication (or their generic equivalents) that I have not drawn a line through and initialed per theStanding Orders of the Camp Physician.
Signature of Parents/Guardian_______________________________ Date(or participant if 19 or over)


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