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Camp beausite northwest

CAMP BEAUSITE NORTHWEST
ADULT - Medication and Medical Care
Requirements and Authorizations
Page 1 of 2

Dear Parent/Guardian/Camper,

Please read the list below and follow the directions carefully:
 There are three pages included in this document that MUST be signed by the legal guardian and/or the health care
provider in order for our nursing staff to administer medication and provide basic health care to your camper: 1. Permissions/releases (following, page 2) 2. Medication Authorization 3. OTC Authorization  We stock most basic OTC medications at camp, such as Tylenol, Advil, Ibuprofen, Benadryl, Tums, Pepto Bismol, Kaopectate, Calamine lotion and hydrocortisone, etc. OTCs are provided to your camper free of charge. You can check
with us in advance to see if we have a specific OTC your camper needs. PLEASE DO NOT BRING TO CAMP.
 All medications brought to camp must be in the original containers with complete and legible labels. Pharmacy blister  Make sure quantities of medication you bring to camp are sufficient for five days. We cannot refill.
 Remember, your camper will only be at camp for 5 days. Please do not send any medications that are not necessary
for this short duration of time.

 Camper will not be allowed to attend camp without Physical Exam Form, signed by a licensed medical care provider
and submitted to camp no later than June 2nd. The physical exam must be conducted within 1 year of the start of
your camper’s session.
PERMISSION/RELEASE

CAMPER NAME: __________________________________________________

Page 2 of 2

Please read carefully, initial each paragraph below, and sign:
I hereby give permission to Camp Beausite NW medical staff to provide routine health care and first aid; to administer approved
medications; to release any records necessary for insurance purposes; and to provide, or arrange, necessary transportation to
access medical care deemed necessary for my camper. ______ (Initial) ________ (Initial)
In the event I cannot be reached in an emergency, I hereby give permission to the healthcare provider selected by the camp
medical staff to administer necessary treatment, including x-rays, routine tests and treatment, injections, surgery, and
hospitalization, for _____________________(the camper). _______ (Initial) _______ (Initial)
I hereby release and waive claim, cause or action, which may accrue against Camp Beausite NW, any employee thereof, or any
other persons acting with their permission, for any injury that may happen to the camper during his/her stay at Camp Beausite
NW , or during any activity approved by any of the said persons. ______ (Initial) ________ (Initial)
_______________________________________
_______________________________________ Camp Beausite Northwest
ADULT (18 years and older) Medication Authorization
Page 1 of 2
CAMPER NAME: _____________________________________________________________ DOB _______________________

ALLERGIES:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Please provide a complete list of ALL medications taken by this individual including: PRESCRIPTION,
OVER THE COUNTER AND HERBAL REMEDIES.

Unless medically necessary to do otherwise (and camp nurse notified), medications will be
administered at the following times: 8:00a.m. (breakfast); Noon, lunch; 5:00pm (dinner); and 8:00 pm
(bed time)

MEDICATION
MEDICATION
Column II
Page 2 of 2
CAMPER NAME: ______________________________________________
No medication will be dispensed to campers without the signature of a licensed health care provider.
I have reviewed the above medication/s and direct that they be provided to the above named camper as
described.

Signature of licensed provider:______________________________________ Date:_____________________
Parent/Guardian Consent: By signing below, I give permission for the above named camper to receive
the medications and dosages listed above for the symptoms specified.

Parent/Guardian/Camper Signature: _____________________________ Date: __________________
Nurse Review (Signature): ______________________________________ Date: __________________
Page 1 of 4
CAMP BEAUSITE NORTHWEST
ADULT - OTC Medication Authorization
CAMPER NAME: __________________________________________________________________________________________
I authorize the use of the following OTC medications to be used for their intended purposes on an as
needed (PRN) basis. A check has been placed before each of the medications that may be administered.
All medications are to be given for a maximum of two consecutive days.

______________________________________
_______________________________
Parent/Guardian/Camper Signature
Date
Headache/Pain/Fever Medication (choose one only)
____ Acetaminophen (Tylenol) 325mg 1-2 tabs, OR LIQUID EQUIVALENT, for headache, pain or fever >100.5.
____
Acetaminophen (Tylenol) 500mg 1-2 tabs, OR LIQUID EQUIVALENT, for headache, pain or fever >100.5.
____
Ibuprofen (Advil/Motrin) 200mg 1-2 tabs, OR LIQUID EQUIVALENT, for headache, pain or fever >100.5.
Antihistamine/Allergy Medication:
____ Diphenhydramine (Benadryl) 25 mg 1-2 tablets, OR LIQUID EQUIVALENT, for itching, rash, allergic
reaction
Menstrual Cramps (choose one only):
____
Acetaminophen (Tylenol) 325mg 1-2 tabs, OR LIQUID EQUIVALENT, for menstrual cramps.
____
Acetaminophen (Tylenol) 500mg 1-2 tabs, OR LIQUID EQUIVALENT, for menstrual cramps.
____ Ibuprofen (Advil/Motrin) 200mg 1-2 tabs OR LIQUID EQUIVALENT, for menstrual cramps.
Cough Medication (choose one only):
_____ Non-Narcotic cough suppressant/expectorant (Robitussin) 2 tsp (10 cc), for cough.
_____ Non-Narcotic, Sugar Free, cough suppressant/expectorant, 2 tsp (10cc), for cough.
Sore Throat:
____ Cough Drops (Cepacol/Sucrets/Chloraseptic) 1 lozenge, for sore throat (up to 10 drops per day)
CAMPER NAME: _________________________________________
Page 2 of 4
Nasal Congestion:
Pseudoephedrine HCL (Sudafed) 30rng 2 tabs, for nasal congestion due to colds, sinusitis. Nausea/Upset stomach/Acid Indigestion/Gas:
____ Alum/Magnesium Hydroxide Liquid w/Simethicone (Mylanta), 2 TBSP (30cc)
____ Pepto Bismol, 2 TBSP (30 cc)
____ Simethicone (Gas-X, Mylanta Gas) 1-2 tabs after meals, for gas. Do not exceed 4 tabs per day.
Constipation:
____ Milk of Magnesia 2 TBSP (30 cc) (followed by 8 ounces of water), for constipation for a maximum of 2
consecutive days.
Diarrhea (choose one only):
____ Kao-pulgite (Kaopectate) 2 TBSP (30cc), for diarrhea. Give a dose after each loose bowel movement for
a maximum of 8 tablespoons in a 24 hour period.
____ Pepto Bismol, 2 TBSP (30cc), for diarrhea. Give a dose after each loose bowel movement for a maximum
of 8 tablespoons in a 24 hour period.
____ Loperamide HCL (Imodium) liquid 4 tsps (20 cc), for first loose bowel movement and 2 tsps (10 cc) after
each other loose bowel movement for a maximum of 8 teaspoons (40 cc) within a 24 hour period.
____ Water in Ear: Swim Ear (or like product) 2-4 drops, for water in ears
____ Eye Irritation: Visine eye drops (or like product) 1-2 drops per eye, for red, itchy eyes


CAMPER NAME: _____________________________________________

Page 3 of 4

First Aid Topicals:
Anti-bacterial:
____ Bacitracin 500units, for minor abrasions.
____ Triple antibiotic cream, for minor abrasions.
Anti-infective:
____ Hydrogen Peroxide full strength as a cleaning agent for minor cuts and abrasions on the skin. May be used
TID
Anti-septic:
____ Betadine solution. Apply full strength (paint/spray) for wound disinfection, abrasions, and emergency
lacerations.
Minor Skin Irritations/Itching:
____ Hydrocortisone 1%. Apply to affected area TID, for the temporary relief of minor itching.
____ Anti-itch lotion (Caladryl). Apply to affected area TID, for relief of itching due to minor skin irritations.
____ Calamine lotion (topical protectant): apply to affected area freely TID pm for itching due to insect
bites/poison ivy/poison oak.
Minor Burns:
____ Anesthetic spray (Dermoplast). Apply to affected area TID, for relief of minor burn discomfort.
Chapped/Cracked lips:
____ Blistex. Apply to chapped/cracked lips.
_____ Vaseline. Apply to chapped/cracked lips.
Muscle Relaxer:
_____ Mineral Ice/Ben Gay. Apply to affected muscles up to TID for sore muscles.
CAMPER NAME: ________________________________________
Page 4 of 4
OTC MEDICTIONS NOT SUBJECT TO 2 CONSECUTIVE DAY LIMIT:

____ Sunscreen (SPF 30 or greater). Apply lotion/spray liberally to exposed skin pm 30 minutes prior to
exposure to sun when deemed necessary by nursing and/or counselor staff. Maybe reapplied as needed after
swimming/exercising/perspiring heavily.
____ Insect Repellant. Apply spray/lotion to exposed skin prior to outdoor activities when deemed necessary by
nursing and/or counselor staff.
Signature of licensed practitioner: _________________________________ Date: __________________________
Printed Name: __________________________________________________ Phone number: ______________

Nurse Review (Signature): _____________________________________ Date: _______________________

Source: http://campbeausitenw.org/wp-content/uploads/2013/10/2014-Adult-Medication-and-Medical-Care-Requirements-and-Autorizations.pdf

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