Health Hut Authorization

Camper First and Last Name*
Shooting Star Adventures/Camp Two Roads/Ohdaka

Health Hut Authorization Guidelines

1. All medication will be maintained and administered by the nurse. This includes prescriptions, over-the-counter and vitamins/supplements. Campers may only carry emergency asthma inhalers and auto injectors for severe allergic reactions (with parent authorization

2. To avoid delays at check in - please follow the directions for each type of medication below.

ALL MEDICATIONS: (prescription, over-the-counter and vitamins/supplements)

A Parent or Legal Guardian must complete and sign the authorization form.

Include the following:
- Name of medication Dose (strength and how much) of medication
- Time and Dates to give medication Purpose or reason for medication
- All medication must be in the original container.
No medication will be accepted or given if sent to camp in unapproved containers (i.e., envelopes, baggies, pill planners etc.)

Prescription medication must have an accurate label. This includes samples given by health care providers. If the directions on the prescription label are different from what the health care provider is currently prescribing, written instruction is required from the health care provider.

Vitamins / supplements are not FDA approved and cannot be given without a note from the Health Care Provider, see OAR 581-021-0037. The note needs to include name of camper, name of vitamin / supplement, dose, time, purpose, signature from health care provider and date. (Examples: melatonin, lactaid, probiotics, daily vitamins, herbs, homeopathic supplements, enzymes

Over-the-Counter OTC is not the same as vitamins / supplements. Over-the-counter medicine is approved by the FDA. Please label the container with your camper's name. If the directions on the label are different from what the health care provider is currently prescribing, written instruction is required from the health care provider.

Inhalers and Auto-Injectors All inhalers must be clearly labeled with the camper's name using a permanent marker.
Sign to allow your camper to carry and self-administer their emergency asthma inhaler and/or auto injector.

Your child must be developmentally and behaviorally able to carry and self-administer his/her inhaler and/or auto injector.
Legal Parents or Guardians Signature

Clear
Medical Transport - Legal parents/guardians are contacted first whenever possible. In case of medical or surgical emergency, I hereby give permission to Camp Two Roads staff to arrange transport for my child, as named above, to the hospital for evaluation by a physician.
Health Insurance Carrier*
Physicians Name*
Physicians Phone Number*
Legal Parents or Guardians Signature*

Clear
Date*

MonthDayYear
Date
Over-the-Counter Medication Release

The Oregon Health Authority requires camps to obtain written permission to administer specific over-the-counter treatments used for common ailments such as headache, poison oak, upset stomach, or diarrhea. Dosage will be administered according to official directions written on the product unless otherwise directed by official physician instructions for the following OTC meds our Health Hut has on hand.

Medications On-Hand in the Health Hut:
Antihistamine
Benadryl
Claritin
Ibuprofen
Acetaminophen
Aspirin
Antacid tablets
Sunscreen
Calamine Lotion
Vaseline
Antibiotic Ointment
Non-medicated Cough Drops
Lidocaine cream or spray
Miralax, stool softener
Shooting Staf Adventures staff is allowed to administer to my camper any over-the-counter medications listed above if necessary for my child, with the exception of any I previously excluded in the registration document.
Legal Parents or Guardians Signature*

Clear
PARENT/GUARDIAN AUTHORIZATION TO ADMINISTER ADDITIONAL MEDICATIONS.

(Prescription, Over-the-Counter, Vitamin/Supplements, Inhaler, Auto-Injector)
1st Medication Name
Time of Day
Dosage
Dates to be Given
Purpose of Medication
- 2nd Medication Name
- Time of Day
- Dosage
- Dates to be Given
- Purpose of Medication
- 3rd Medication Name
- Time of Day
- Dosage
- Dates to be Given
- Purpose of Medication
- 4th Medication Name
- Time of Day
- Dosage
- Dates to be Given
- Purpose of Medication
- 5th Medication Name
- Time of Day
- Dosage
- Dates to be Given
- Purpose of Medication
- 6th Medication Name
- Time of Day
- Dosage
- Dates to be Given
- Purpose of Medication
- (This authorization applies only to the medication listed above and for the duration of treatment or week. This also authorizes an exchange of information, as necessary, between the nurse, appropriate camp personnel, my camper's health provider, and/or my camper's pharmacist
- Legal Parents or Guardians Signature
  
  Clear
- Date
  
  MonthDayYear
  Date
- Should be Empty: