Medication & Treatment Release Form

Camper's Name *
Camper's Name
DO NOT Give the Following Medications to this Camper
Check all that you do not want the camp to give this camper under any circumstances.
Request for Contact Before Given Medications *
Please list the name of medication, dosage/arnt., time given and any additional instructions.
Two Responsible Parties Other Than Yourself
Please list two responsible parties OTHER THAN yourself that we should contact regarding care of your child if we are unable to reach you in the case of a medical emergency.
Other Responsible Party One
Other Responsible Party One
Phone
Phone
Other Responsible Part Two
Other Responsible Part Two
Phone
Phone
Typing your name and submitting this form indicates the following: I hereby give permission for the above camper to receive necessary first aid care, which may include, but is not limited to, use of antiseptic wash, antibiotic ointment, bandages and hydrocortisone cream. I also approve of the administration of the following oral medications (in the recommended dosage for my child's age/weight) as requested by my child or at the discretion of the camp nurse to treat appropriate symptoms.
Date Signed
Date Signed
Primary Contact Number
Primary Contact Number