Prescription and Over-The-Counter Medication Form

ALL medications MUST
be in its original bottle.

Name of Camper*

First NameLast Name

Session(s) Attending:*

Name of Medication*

Dosage*

Route*

Frequency*

Duration*

Instruction*

Conditions when physician should be contacted*

If you are bringing more than 1 medication, please submit another form.
One form for each medication.