Midcourse Medical Form

Medical Form
Camper Name*

First NameLast Name
Camper DOB*

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Date
Camp Date

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Date
Please complete this form even if your child does not take any prescription medications. Please list all medication that your child will need to take during the weekend camp, if any. The medical officer will oversee administration of all medications; campers are not allowed to keep any medications on them or in their gear. Please send enough medication for the entire weekend at camp in the original package/bottle that identifies the prescribing physician, the name of the camper, the name of the drug, the dosage, and the frequency at which it must be taken. Prescription medications will only be accepted with the original prescription container. This includes rescue inhalers. If medications are brought in any container other than the original, you will be asked to visit the local pharmacy to obtain a copy of the prescription at your own time and expense. Medications are given at mealtimes and bed; please make a note and speak with the medical officer at registration if medications must be given at other specific times.

Medications to be Given AT CAMP

I, Parent/Guardian, confirm that the medication, dosage, and distribution information listed above is correct.*

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Printed Name
Date Completed*

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Date
Knowing and understanding your child’s medical history helps us to provide the best care possible to your child. Please check the boxes below if your child has any known diagnosed medical conditions Midcourse staff should be aware of. Use the space below to explain any checked items.*

My child has no known /diagnosed medical conditions.Asperger'sAutismADDADHDLearning DisabilityAnxietyDepressionEating DisorderOther psychiatric/ behavioral issuesDiabetesSeizuresAsthmaCardiac ConditionsAny injury or illness requiring stitches, casts, splints, etc.Type option 16Other
Condition(s) Explanation
Does your child have any allergies (food, medication, environmental?

YesNo

Please list allergies and reactions.

Medical officers are trained to provide basic first aid during the weekend. Below is a list of over-the-counter (OTC) medications the medical officer has available to your campers if/when they need it. All OTC medications will be given following manufacturer’s recommendations. These are provided at no cost to you. By signing this form and sending your child to camp, you give the medical officers permission to administer OTC medications. If you do NOT want your camper to receive any of the below medications for any reason, please cross it off the list. Please note most oral medications are in pill/tablet/capsule form. Please note some medications are generic and some are brand name. If you have any questions, please call the office or come see the medical officer at registration.

FOR STAFF USE ONLY

	Date	Time	Dose	Camper	Medic
For Pain:
Acetaminophen (generic Tylenol)
Ibuprofen (generic Motrin)
Naproxen (generic Aleve)
Menstrual Relief (generic Midol)
Headache Relief (generic Excedrin)
For Allergies:
Diphenhydramine (generic Benadryl)
Fexofenadine (generic Allegra)
Famotidine (generic Pepcid)
For Gastrointestinal/Upset Stomach:
Pepto-Bismol
Calcium Carbonate (generic TUMS)
For minor cuts, wounds, topical:
Triple ABX ointment (generic Neosporin)
Hydrocortisone cream
Antifungal cream
Talcum powder (generic Monkey Butt, Gold Bold Foot Powder)
Poison Ivy Cream
Petroleum Jelly (generic Vaseline)

blanks Please initial if you DO NOT want OTC medications given without your knowledge.
I, Parent or Guardian, confirm that (child’s name) blanks 's medical information above is complete and accurate.
Signature*

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Date*

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Should be Empty: