Camper Medication Form

Camper Medication Form

This form must be completed for any prescription and over-the-counter medication sent to camp. Please note: all medications need to be brought to camp in the ORIGINAL prescription containers and packaging. No loose medications will be allowed at camp.
Camper Name*

First NameLast Name
Camper's preferred first name*
Gender*

MaleFemale
Birth date*

MonthDayYear
Age group*

2-4 grade division5-6 grade division7-9 grade division10-12 grade divisonCILT camperAdult counselor
Parent/Guardian Contact Information

If we have any questions, who do we contact?
Parent/Guardian name*
Relationship*
Cell Phone*

Area CodePhone Number
Email (confirmation will be sent by email)*
example@example.com
Medications

List one medication in each field. Please make sure to give the medicine name, what it treats, dose, time to give, and any special instructions. For example: “diphenhydramine, give 25 mg for itching related to grass allergy every 4-6 hours"
Medication #1
Medication #2
Medication #3
Medication #4
Diabetic instructions - please specify if Type 1 or 2 and give any special needs.
Should be Empty: