2011 medication notice

Medication Notice
This notice is extremely important so please read it carefully and initial on each line below, follow the
instructions completely and sign the consent at the bottom of this page. If you disagree with any of the
statements here, please cross out that section and initial it. Explain your wishes in the comments section or
attach an additional sheet if necessary.

ALL Campers/Staff who bring medications to camp must meet the following REQUIREMENTS:
______ The Physician who ordered the medication (s) has completed, dated, and signed an authorization form for
each medication individually . If there is more than one physician prescribing medications, then each individual
must submit a form with the medications they prescribed listed.
______ The Physician (s) has listed all the medications the camper is bringing to camp and note if said medication (s)
______ALL over the counter drugs must be in the original bottle/box, labeled and have the person’s name written
on it.
______The Camper/Staff knows what medications they are taking and how important it is that they report to the
health lodge to take them as prescribed.
______On Registration day, bring the medications in a bag with the name of the camper/staff member on it. ______ Please bring only the number of pills that will be needed for the week (and maybe a few extra in case one
drops) since the nurse must count all of the medications brought and enter them in to a log.
______ I give permission for the Camp Health Officer to administer over the counter medications for conditions as
directed by the Camp Physician.(the over the counter medications may include WOUNDS: Betadine, Hydrogen
Peroxide, Bacitracin antibiotic ointment, POISON IVY: Tecnu, Benadryl cream CANKER SORES: Benzocaine
Cream PAIN: Tylenol, Ibuprofen, DYSMENORRHEA: Ibuprofen ABDOMINAL DISCOMFORT: Tums, Maalox
HEADACHES: Tylenol, Ibuprofen HYPOGLYCMIA: Glucose gel, Glucagon ALLERGIC REACTION:
Benadryl or generic, Epipen ATHLETE’S FOOT: Tinactin INSECT STING/BITE: Benadryl cream, Hydrocortisone
cream, Caladryl or Calagel, Epipen TICK BITES: Alcohol or Hydrogen Peroxide 1ST DEGREE BURNS: Burn Jell,
Aloe Spray EMERGENCIES: Oxygen, Generics may be substituted.

IMPORTANT for minors: In
case of il ness or accident during the trip to and from the New Heights Summer Camp, or while at camp, and when
New Heights is unable to contact us through reasonable effort, we the self/parents/guardians of _______________________________, hereby
consent to the giving of any and al emergency medical care to our child named above that may be deemed necessary by an official of the Camp
in consultation with any physician or hospital without obtaining further consent. I agree to the release of any records necessary for treatment,
referral, bil ing or insurance purposes.
Parent/guardian’s signature

Source: http://www.newheightscamp.com/forms2011/2011%20Medication%20Notice%20only.pdf


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Microsoft word - standing orders and physical form09.doc

Camper Name: ____________________________________________ Date of Birth: ________________ This MUST be completed by a licensed PHYSICIAN and is REQUIRED for camper ATTENDANCE. Standing Orders: *Form must be filled out each year. Attention Physician: The following Over-the-Counter medications will be available in the Health Center. Administration of these medications is “per label directions

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