Mountain Harmony Camp

Region 12, Sweet Adelines International

Camp Dates: Fri., Nov. 22, 2024 - Sun., Nov. 24, 2024

 ASTHMA / INHALER

As the parent/guardian of this child, I acknowledge that my child is responsible for, and competent in the appropriate use of, her prescribed asthma inhaler. I authorize my child to possess/carry her own prescribed asthma inhaler while at camp. I have provided a second inhaler to the Camp Nurse in case of loss or other emergency.

EpiPen / Twinject / Auto Injector

As the parent/guardian of this child, I acknowledge that my child is responsible for, and competent in the appropriate use of, her prescribed Epinephrine Auto-Injector. I authorize my child to possess/carry her own prescribed injector while at camp. I understand the Camp Nurse, or other designated adult, will immediately request assistance from an emergency medical service provider if this medication is administered. I have provided a backup dose of this medication to the Camp Nurse in case of loss or other emergency. 

As the parent/guardian of the above-named child I have read and complied with the following Mountain Harmony Camp rules for administering medication while at camp and herby give my permission for administration.

• The medication must be in its original container, with a legible label from the pharmacy, indicating the child's name, date, name of medication, expiration date, dosage, time and number of days medication is to be given, the doctor/nurse practitioners name, pharmacy name and telephone number.

• Over the counter medications must also be in their original containers and labeled with child's name

• Any medication samples must be accompanied by a doctor's written prescription.
• Medications are to be given only to the child indicated on the label (twins / siblings cannot share)

• Label constitutes the physicians/nurse practitioner's order                             

• As the parent/guardian of the above-named child, I give permission for the designated Camp Nurse to administer the prescribed, or non-prescribed, medication(s) listed below to my child. The undersigned agrees not to file or make any claim for negligence in connection with the administration or non-administration of this medicine(s) and further agrees to hold Sweet Adelines International, Pacific Shores Region 12, their representatives and the Camp Nurse harmless from any liability incurred as a result of the administration or non-administration of any medicines listed.