CAMP FLIX MEDICAL & EMERGENCY CONTACT FORM Logo
  • CAMPER MEDICAL & EMERGENCY CONTACT FORM

    CAMPER MEDICAL & EMERGENCY CONTACT FORM

    • Section I. CONTACT INFORMATION 
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    • Emergency contact if parent cannot be reached:

    • Section II. MEDICAL INFORMATION 
    • Dietary Restrictions 
    • Medical History 
    • In order to ensure the utmost health, safety, and support for your camper in the best way possible at camp, we ask that you please disclose the following information:

    • Immunization 
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    • Medication Signature & Consent 
    • I CONSENT TO HAVE THE ADMINISTRATORS OF CAMP FLIX ACT ON MY BEHALF SHOULD AN EMERGENCY ARISE, AND HEREBY GRANT PERMISSION TO AUTHORIZE MEDICAL ATTENTION RECOMMENDED BY A PHYSICIAN, NURSE, OR HOSPITAL

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  • MEDICATION ADMINISTRATION AUTHORIZATION FORM

  • This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the camper to self-administer medication under staff supervision. A new medication administration form must be completed at the beginning of each camp season, and each time there is a change in dosage or time of administration of a medication.

    Prescription medication must be in a container labeled by the pharmacist or prescriber.

    Nonprescription medication must be in the original container with the instructions for use. Non prescription medication includes vitamins, homeopathic, & herbal medicines.

    An adult must bring the labeled medication to the camp and give the medication to an adult staff member.

    Campers must come to camp staff administrators each time they need to take their medication. The only medication campers are allowed to self-carry include emergency medications such as epi-pens.

    • Section I. MEDICATION ADMINISTRATION 
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    • Section II. PARENT/GUARDIAN AUTHORIZATION 
    • I request the authorized youth camp operator, staff member or volunteer to administer the medication or to supervise the camper in self-administration as prescribed by the above authorized prescriber. I certify that I have legal authority to consent to medical treatment for the child named above, including the administration of medication at the facility. I understand that at the end of the authorized period an authorized individual must pick up the medication; otherwise, it will be discarded. I authorize camp personnel and the authorized prescriber indicated on this form to communicate in compliance with HIPAA.

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