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Camp beausite northwest
CAMP BEAUSITE NORTHWEST
ADULT - Medication and Medical Care
Requirements and Authorizations
Page 1 of 2
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.
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 _______________________
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
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
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.
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.
Diphenhydramine (Benadryl) 25 mg 1-2 tablets, OR LIQUID EQUIVALENT, for itching, rash, allergic
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.
Cough Drops (Cepacol/Sucrets/Chloraseptic) 1 lozenge, for sore throat (up to 10 drops per day)
CAMPER NAME: _________________________________________
Page 2 of 4
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.
Milk of Magnesia 2 TBSP (30 cc) (followed by 8 ounces of water), for constipation for a maximum of 2
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:
Bacitracin 500units, for minor abrasions. ____
Triple antibiotic cream, for minor abrasions.
Hydrogen Peroxide full strength as a cleaning agent for minor cuts and abrasions on the skin. May be used
Betadine solution. Apply full strength (paint/spray) for wound disinfection, abrasions, and emergency
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.
Anesthetic spray (Dermoplast). Apply to affected area TID, for relief of minor burn discomfort.
Blistex. Apply to chapped/cracked lips.
Vaseline. Apply to chapped/cracked lips.
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: _______________________
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