2024 Jr Tracker Camp Medical Form

AUTHORIZATION FOR ADMINISTRATION OF SEVERE ALLERGY OR PRESCRIBED MEDICATIONS*

PART I (TO BE COMPLETED BY A PHYSICIAN, ONLY IF APPLICABLE)
Parents to Physician: I/we wish to enroll our child (your patient),blanks*, in the Jr Tracker & Wilderness Exploration camp. We are requesting that they provide certain emergency care for the prevention of anaphylaxis if our child comes into contact with a certain allergen(s), as described below. Please complete Part I of this form. This record will remain on file at Amethyst Retreat Center during the course of the camp. If you need to provide further instruction or clarification, please document separately, to serve as an addendum to this form.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Allergies or Prescribed Medication: Please provide a complete list of all events and/or substances that may trigger a severe allergic reaction(anaphylactic shock).*

Bee StingOther Insect BitesFood AllergiesAnimal FurOther Allergies/Health ConditionsNo Allergies/Health Conditions
Please identify which insect bites will cause allergic reaction (if any):
Please identify which foods will cause allergic reaction (if any):
Please identify which animal furs will cause allergic reaction (if any):
Please identify any other allergies or health conditions (if any):
Child will Bring:*

InhalerDiabetes DeviceOther MedicationNone of These
If you chose "Other Medication", please identify what medication the child will be bringing:
Name of Drug:
Dosage:
Frequency:
Time for Dosage:
Child Will Self-Administer

YesNo
Route:
Date of Rx:
Please provide a complete list of all symptoms that indicate the child has come in contact with an allergen, that he/she/they require(s) emergency treatment, or is in need of the medication listed above.
Physician’s Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Signature

Clear
Today's Date

MonthDayYear
Date
*Submission of this form is not required if your child does not have any known medical issues requiring medication.
PART II (TO BE COMPLETED BY PARENT(S)/GUARDIAN(S), ONLY IF CHILD IS TO SELF-ADMINISTER MEDS.)
My child has the knowledge and skills to safely administer his/her/their medication, and is capable of self-administering his/her/their medication without assistance, and is responsible with the medical device/medication.
Parent/Guardian Signature:

Clear
Today's Date

MonthDayYear
Date
By signing below, I/we authorize Amethyst Retreat Center and its designated agents to follow the instructions as outlined in this form by my child’s physician, including the administration of medication. I/we agree to update this form immediately if any changes take place. I further authorize Amethyst Retreat Center and its designated agents to contact my child’s physician listed above.
Signature:

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR ADMINISTRATION OF SEVERE ALLERGY OR PRESCRIBED MEDICATIONS*

PART II (TO BE COMPLETED BY PARENT(S)/GUARDIAN(S), ONLY IF CHILD IS TO SELF-ADMINISTER MEDS.)