Path of Life Camp
*No medications (including over the counter) will be given at camp without this completed form (signed by your provider) on file.
All medications must be checked into the camp health office on arrival. Campers are not allowed to keep any medicine, including vitamins, in the dormitory or cabin. A parent, guardian, or responsible adult shall deliver all medications to the camp health office.
All medications must be in a pharmacy or manufacturer labeled container.
Camper's name: ____________________________________ Birth date: _________________________
Week(s) of: __________________________________________________________________________
Check all that apply. We supply the following medications at camp:
______Ibuprofen - Please give _____ (200mg) tabs every 6 hours as needed for discomfort
Please give _____ tsp. every 6 hours as needed for discomfort
______Acetaminophen - Please give _____ (325mg) tabs every 4 hours as needed for discomfort
Please give _____ tsp. every 4 hours as needed for discomfort
______Diphenhydramine HCL (Benadryl) - Please give _____ (25mg) tabs every 4-6 hours as needed for discomfort
Please give _____ tsp. every 4-6 hours as needed for discomfort
______Topical Benadryl - apply per package directions as needed
______Antibiotic ointment - apply per package directions as needed
List any other prescription or over the counter medication this child will need at camp (include name of medication, dose, frequenc, time to be given).
Licensed Health Care Provider Signature_____________________________Date_____________
Licensed Health Care Provider (PRINT or STAMP NAME) ___________________________________________
I request that my child_____________________________________, date of birth ______________ receive the medication(s) listed above and prescribed by the health care provider. I understand that this medication will be destroyed if it is not picked up within one week following the ned of his/her week at camp.
Parent/Guardian's signature: _____________________________ Date: ____________________