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Medication Process

  • ANY prescription or routine over-the-counter(OTC) medications will be given to the Camp Nurse PRIOR to camp and they will be dispensed at camp.


  • The Camp Nurse will have stock OTC meds such as Tylenol, Ibuprofen, antacid, Benadryl, etc. that your camper can request (you can give that permission on the TC Release Form)


  • Fill out your campers medications below.


  • Bring ALL daily meds to the Camp Nurse during the parent meeting for processing.


  • Only send enough doses for the camp week (pills or capsules). We will provide small medical envelopes for meds.


  • Mark inhalers or other medical devices with campers name.


  • If your camper is sent with an inhaler or medical device, it will be returned to the camper as we depart camp for our transport home. If special arrangements other than that need to be made, submit your request in writing to Camp Nurse.


Dated: March 12, 2025


First Camper's Name

First Name*

Last Name*
First Camper's Date of Birth*
First Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

First Camper's Signature*
Second Camper's Name

First Name*

Last Name*
Second Camper's Date of Birth*
Second Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Third Camper's Name

First Name*

Last Name*
Third Camper's Date of Birth*
Third Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Fourth Camper's Name

First Name*

Last Name*
Fourth Camper's Date of Birth*
Fourth Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Fifth Camper's Name

First Name*

Last Name*
Fifth Camper's Date of Birth*
Fifth Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Sixth Camper's Name

First Name*

Last Name*
Sixth Camper's Date of Birth*
Sixth Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Seventh Camper's Name

First Name*

Last Name*
Seventh Camper's Date of Birth*
Seventh Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Eighth Camper's Name

First Name*

Last Name*
Eighth Camper's Date of Birth*
Eighth Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Ninth Camper's Name

First Name*

Last Name*
Ninth Camper's Date of Birth*
Ninth Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Tenth Camper's Name

First Name*

Last Name*
Tenth Camper's Date of Birth*
Tenth Camper's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Parent or Guardian's Email Address

Email*
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Cell Phone Information:

Mom Cell *

Dad Cell
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

MEDICATIONS:



Drug Name & Dosage #1
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #2
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #3
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #4
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

Drug Name & Dosage #5
Time of Day Given:*
AM
PM
Both AM & PM
As Needed

SPECIAL INSTRUCTIONS: (if so, type it out in the box and reference the Drug #'s above.

I declare that the information listed on this form is correct and complete. I hereby give permission for the Camp Nurse to administer the medication(s) as directed above.

Parent or Guardian's Signature*
Electronic Signature Consent*
 I declare that the information listed on this form is correct and complete. I give permission for the Camp Nurse to administer the medication(s) as directed above.


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