Instructions for Administering Medication

Please send this form with the Camper Full Name of Camper:
Name, cell phone and email address of primary contact for questions relating to camper’s medication:
Name:
Cell phone number:
E-mail address: * required
Name of camper’s primary physician:
Phone number:

Medications taken daily:
Please indicate the name of the medication with dosage, number of pills, and time medicine should be given.
Time Given Name of Medicine Dosage Number of Pills
Before breakfast:
 
 
At breakfast:
 
 
Mid-morning:
 
 
Lunch:
 
 
Afternoon:
 
 
At dinner:
 
 
Evening:
 
 
At bedtime:
 
 

Special instruction for any of the medications listed?


Medications to be given only as needed:
Indication (reason to administer medicine) Name of Medicine Dosage Number of Pills


Seizures Does the camper have seizures?
Yes No
Are there any known circumstances that may cause a seizure such as heat or fatigue?

When was the camper’s last seizure?


If camper experiences a seizure:
Do you want emergency medical services to be called? Yes No
Do you want to be called? Yes No

Instructions if a camper has a seizure:


Please make sure that you have included enough medication for the length of the camper’s stay at the camp!


Verification code:
Re-type verification code:
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