Camp Medication Form

Name: ______________________________ Dates attending: ___ / ___ / 20____   to   ___ / ___ / 20____

Medications

Medication and reason for use (Example: Amoxicillin for ear infection)	Dosage and frequency (Example: 1 tablet, 3x/day)	Check all that apply
		8:30 AM (or ________)   1:00 PM (or ________)   6:30 PM (or ________)   9:00 PM (or ________)   As Needed
		8:30 AM (or ________)   1:00 PM (or ________)   6:30 PM (or ________)   9:00 PM (or ________)   As Needed
		8:30 AM (or ________)   1:00 PM (or ________)   6:30 PM (or ________)   9:00 PM (or ________)   As Needed
		8:30 AM (or ________)   1:00 PM (or ________)   6:30 PM (or ________)   9:00 PM (or ________)   As Needed
		8:30 AM (or ________)   1:00 PM (or ________)   6:30 PM (or ________)   9:00 PM (or ________)   As Needed

All prescription medications MUST be in correctly labeled container with name and dosage.

If your child's name is not on your non-prescription container, please write their name on it.

Parent/Guardian's signature: _____________________________ Date: ____________________


Nurse's signature: _____________________________Date: ____________________