Path of Life Camp
53 Winn Hill Road
Port Crane, NY 13833

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Path of Life Camp

Authorization for Medications

*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).

_______________________________________________________________________________________

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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: ____________________