• 2022 Hoop Camp Medical Forms

  • Camper Information

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  • IN CASE OF EMERGENCY NOTIFY:

  • Primary Care & Health Insurance Information

  • Health Status Section

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  • Parent or Legal Guardian's Authorization For Emergency Care

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  • Authorization For The Administration Of Over-the-counter (OTC) Medications

    ALL OVER THE COUNTER MEDICATION MUST BE IN THE ORIGINAL CONTAINER WITH THE CAMPER’S NAME ON THE BOTTLE. A PARENT’S SIGNATURE IS REQUIRED.
  • OTC Medication #1 (please fill in the blanks below)
    The name of the OTC medication is *
    It is used to treat the following condition*
    The dosage to be given is *

  • OTC Medication #2 (please fill in the blanks below)
    The name of the OTC medication is *
    It is used to treat the following condition*
    The dosage to be given is *

  • OTC Medication #3 (please fill in the blanks below)
    The name of the OTC medication is *
    It is used to treat the following condition*
    The dosage to be given is *

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  • Authorization For The Administration Of Prescription Medications

    All Prescription Medications Must Be In Original Containers And Labeled With Camper’s Name, Name Of Drug, Strength, Dosage, Frequency, and Authorized Prescriber Or Dentist’s Name
  • Prescription Medication #1 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #2 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #3 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #4 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #5 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #6 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #7 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #8 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #9 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #10 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

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  • Authorization/Approval For Self Administration Of Emergency Medication

  • PARENTS/GUARDIANS PLEASE READ: By signing this form you are giving permission for your child to administer lifesaving medications without adult or medical supervision of any kind.Do not sign this form unless the child has a life-threatening condition and self-administers his/her own medication. PARENTS/GUARDIANS PLEASE READ: Dosing instructions or any limitations,notes or comments, such as when these devices can or can’t be used, nullifies the document. 

  • As the parent/legal guardian of *, I consent to the following:

  • Summary of Maine Law on Self-Administration of Emergency Medications


    Recreational camps for children; emergency medication. A recreational camp for boys or girls must have a written policy authorizing campers to self-administer emergency medication, including, but not limited to, an asthma inhaler or an epinephrine pen.

    The written policy must include the following requirements:


    1. A camper who self-administers emergency medication must have the prior written approval of the camper's primary health care provider and the camper's parent or guardian;
    2. The camper's parent or guardian must submit written verification to the camp from the camper's primary health care provider confirming that the camper has the knowledge and the skills to safely self-administer
    the emergency medication in camp;
    3. The camp health staff must evaluate the camper's technique to ensure proper and effective use of the emergency medication in camp; and
    4. The emergency medication must be readily available to the camper.

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  • **To be completed by Camp Nurse**

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  • Release Of Liability And Medical Coverage

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  • Policies and Media Release

  • Click the links below to read the policy documents:


    REFUND POLICY

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