Microsoft word - over-the-counter medication authorization

AUTHORIZATION TO ADMINISTER NON-PRESCRIPTION MEDICATION TO CAMPER
(TO BE COMPLETED BY PARENT/GUARDIAN)
Name of camper __________________________________ Date of attendance______________________

Please check off which non-prescription medications you give permission to be administered by the Health Care
Manager to the above named camper on an as needed basis. All over the counter medications for campers shall
be kept in the original containers containing the original labels, which shall include directions for use.
We stock the following medications so you do not need to bring them with you!

 Acetaminophen(Tylenol): To relieve headaches, minor aches, fever, menstrual cramps. Contains no

 Ibuprofen(Motrin/Advil): To relieve headaches, tooth aches, minor aches, fever, menstrual cramps.
Contains no aspirin. *Caution: people with a severe allergic reaction to aspirin must not take ibuprofen.
 Dyphenhydramine(Benadryl): Contains antihistamine for temporary relief of sneezing, runny nose, itchy
eyes and throat due to allergy and colds and/or pain & swelling due to insect bites.
 Cough Drops: Quiets cough.
 Liquid antacid (Mylanta/Maalox): Provides temporary relief of acid indigestion and/or nausea.
 Sunscreen/insect repellant: (may be applied by counselors)
 Topical ointments(Bacitracin, Calamine, Hydrocortisone, burn gel containing aloe/lidocaine): To
protect against infection or relieve itching/pain from insect bites, rashes or superficial burns. I understand that for any prescribed medications, or over-the-counter medication not listed above, to be administered by the camp staff, an authorization form from the camper’s own doctor will need to be completed. This form was included in the confirmation packet and can be duplicated if required. Each prescribed medication will need an individual authorization. I further understand, that all medications, both prescribed and over the counter, are required to be in the original container. This requirement covers vitamins and homeopathic remedies. Parent/Guardian Signature_____________________________________Date:___________ DATE OF ADMINISTRATION

Source: http://camphowe.org/camper_forms/otc_administration.pdf