Medication Form 2019 (REQUIRED BY ALL)
CAMP WEEKANEATIT 2019 CAMPER MEDICATION FORM
In addition to the other camper required forms---
1. you MUST complete this form (EVERYONE-please indicate N/A if your camper takes NO meds--but still submit form.
- If your camper takes ANY medication on a regular basis (over the counter or prescription, vitamins…) AND any prescribed medications taken as needed to be administered at camp.


If your camper has ANY medication changes prior to camp--You MUST come back to this form and submit a newly updated one prior to camper check in.

Packing/ bringing meds to camp:
1. Campers must bring enough medication for (7) days.
2. Prescription medicine AND over the counter medication must all be in the ORIGINAL LABELED PILL BOTTLE(S). This includes—if needed your child’s epi pen and inhaler.
3. You must place all the bottles into a large zip-lock bag with the child’s name on it.
4. You will be asked to go over the medication procedure with the nurse when you arrive for accuracy.
5. DO NOT PLACE IN LUGGAGE! You will need to access it during check-in!

Camper Name *
Your answer
Parent Name (who is completing this form) *
Your answer
Please check one of the options below: *
Prescription AND Over the counter Medications: please list each medication in this and the subsequent questions below with all of these fields included: medication/ mg/ dosage/ administration schedule/ special notes (Please put N/A if you have no prescription meds) MEDICATION #1 *
Your answer
continued medication list: MEDICATION #2: medication/ mg/ dosage/ administration schedule/ special notes (Please put N/A if you have no prescription meds) *
Your answer
continued medication list: MEDICATION #3: medication/ mg/ dosage/ administration schedule/ special notes (Please put N/A if you have no prescription meds) *
Your answer
continued medication list: MEDICATION #4: medication/ mg/ dosage/ administration schedule/ special notes (Please put N/A if you have no prescription meds) *
Your answer
continued medication list: MEDICATION #5: medication/ mg/ dosage/ administration schedule/ special notes (Please put N/A if you have no prescription meds) *
Your answer
continued medication list: MEDICATION #6 PLUS: TYPE IN MED #6 and any additional meds: on each line include: medication/ mg/ dosage/ administration schedule/ special notes (Please put N/A if you have no prescription meds) *
Your answer
Prescribed epi pen and/or inhaler. I understand that if my child has been prescribed an epi pen and/or inhaler that I need to bring this to camp for the camper to keep on them at all times. *
I understand and agree to the following requirements: Campers must bring enough medication for (7) days. Prescription medicine AND over the counter medication must all be in the original labeled pill bottle(s). This includes—if needed your child’s epi pen and inhaler. Place all the bottles into a large zip-lock bag with the child’s name on it. You will be asked to go over the medication procedure with the nurse when you arrive for accuracy. DO NOT PLACE IN LUGGAGE! You will need to access it during check-in! *
Cell phone we can reach you at DURING CAMP.
Your answer
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