Consent for Administering Over the Counter Medicine
**THE PARENT/GUARDIAN OF CAMPER STATED BELOW MUST FILL OUT THIS FORM**

In order to continue to provide the best care we can for our campers we are requesting that the parent or guardian of each camper review the list of over the counter medications that we keep in the infirmary. These medications are used when campers have complaints/illnesses for which they have no prescription medications available to them. Example: headache- we give Tylenol, dosage age appropriate. We request that you check the appropriate box: YES, my child can take this medicine; or NO, my child can NOT take this medicine.

YOUR CONSENT MUST BE OBTAINED BEFORE ANY MEDICATION IS GIVEN TO YOUR CHILD.

Camper's Full Name *
Your answer
Camp(s) Attending *
Required
Hypodermic: *
Yes
No
Epipen 0.3 mg. Uses: Anaphylactic Shock (usually bee stings)
Inhalation/Oral: *
Yes
No
Acetaminophen, uses: pain relief, fever, headache
Ammonia inhalants, uses: Fainting/near fainting
Benadryl, uses: allergic reaction, severe itching, seasonal allergies
Chlo-Trimeton, uses: seasonal upper respiratory allergies
Chloroseptic throat spray, uses: sore throat
Emetrol, uses: vomiting
Hypo tears, uses: eye irritation
Ibuprofen, uses: swelling, extremity injure ie, sprains
Maalox, uses: indigestion
Robitusin CF, uses: dry coughs
Sucrets Lozenges, uses: sore throat
Sudafed, uses: decongestant
Tylenol, uses: headache, fever
Topical Preparations *
Yes
No
Aloe Gel, uses: insect bites, sunburns
Bacitracin Ointment, uses: antibiotic ointment of minor skin disruption
Bactine Spray, uses: antiseptic and anesthetic
Cool Gen, uses: burns
Caladryl, uses: anti itch/antiseptic for poison ivy, etc.
Calagel, uses: anti itch cream
Hydrocortisone, uses: itching
Off Skintastic, uses: insect repellent spray
Nix, uses: head lice shampoo
Silvadine, uses: burn ointment
Rhuli Gel, uses: Analgestic for minor skin irritations
Sting Kill wipes, uses: anti-itch for bug bites
Sun Screen, uses: sunburn prevention
Tecnu, uses: skin cleanser for poison ivy/oak
Tinacin or Lamisil, uses: athletics foot, other fungal irritations
I, the parent/guardian of the child stated above, state that I have filled this out and by clicking "Yes" I understand that it is equivalent to my signature. *
Today's Date *
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