Daily/Regular Medication Consent Form
By filling out this form, you are agreeing for your child's medications to be packaged and managed through Green Pharmacy, as is Camp Northland policy this summer.
After their time at camp, medications can be transferred back to the original pharmacy upon request.   
You will be contacted by Green Pharmacy to confirm details in the coming weeks. 

Their contact information is below if you have any questions: 
Green Pharmacy 
Phone: 416-530-4004
Text: 416-398-4884
Fax: 416-530-4002 

DEADLINE:  FRIDAY MAY 15, 2024 


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メールアドレス *
Parent First and Last Name: *
Parent phone number: *
Parent Email (if different than the one above): *
Camper First and Last Name: *
Camper's Birthday: *
YYYY
/
MM
/
DD
Camper's Health Card Number (Please include version code)
Current Pharmacy Name: *
Current Pharmacy Phone number: *
Current Pharmacy address (if you have it):
How long will the camper be staying at camp? Please select one.
 *
If you end up extending your child's stay at camp, we will communicate any required steps at that time.
Does the camper have allergies to any medications? *
If you answered yes, please list which medications the camper is allergic to. *
If you answered 'No' to previous question, please enter N/A.
Please list all regular daily medications that are required to be sent to camp. Include the name of the medication, the strength, and the frequency with which it is used. If a medication is used only when needed, please indicate that as well. Be sure to include any medication types, such as:
*oral medications
*inhalers
*creams
*insulin
*diabetic supplies
*epipens
*as needed medications 
*eyedrops
*etc

Example: Fluoxetine 20 mg once daily,  Flovent 50 mcg twice daily, Blexten 10 mg when needed for allergies, Betaderm 0.05% cream when needed for itch/redness, Pataday 0.1% when needed for itchy eyes. 

Feel free to text or call with any questions during this process.
 *
Are there any non-prescription medications or over-the-counter products which the camper uses? Consider: oral medications (allergies, supplements, melatonin, etc.), creams, nasal sprays, etc.  *
Any other relevant health information/supplies needed:
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