IRBC Medication Form 2022

IRBC Medication Form 2022

This form should be filled out for each Youth Camper that has medication that registered via paper form.
Camper Name *

First Name Last Name
Birth Date *

Month Day Year
Gender *

Male Female
Week of Camp *
Medications

All medications must be in the original container and turned into the nurse. Do not send general OTC meds (tylenol, etc.) - if needed, it will be provided by the camp nurse.
How Many Camper Medications? *
Medication Name #1:
Strength:
Route:
Quantity:
Dosage:
Reason:
Comments:

Medication Name #2:
Strength:
Route:
Quantity:
Dosage:
Reason:
Comments:

Medication Name #3:
Strength:
Route:
Quantity:
Dosage:
Reason:
Comments:

Medication Name #4:
Strength:
Route:
Quantity:
Dosage:
Reason:
Comments:

Medication Name #5:
Strength:
Route:
Quantity:
Dosage:
Reason:
Comments:

Health Screening

All campers & counselors must be healthy to attend. Do not come or postpone coming to camp if you have had vomiting, diarrhea, or fever 100+ in the past 24 hours!

Medication:

All medications must be turned into the nurse. It must be in the original container. Please do not send general OTC (tylenol, advil, etc.) if needed, IRBC will provide them.

Please pack medication separately so campers can turn it in to the nurse at check-in.
Parent/Guardian: *

First Name Last Name
Phone Number *

Area Code Phone Number
DateTime
DateTime
Should be Empty: