Permission To Treat Form

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PERMISSION TO TREAT FORM
I, __________________________, give Camp Berger’s health designee permission to provide routine
health care (first aid/CPR), procedures according to the Health Procedures attached.
I understand that all necessary precautions will be taken by Camp Berger for the safety of my child/ren and
that I will be contacted in the case of emergency. Please initial is the space provided.
Please list your child/ren’s names below:
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
Parent Signature
Date
I, __________________________, hereby give Camp Berger’s health designee permission to administer
the following over-the-counter medications if the site director deems it necessary.
Dosages will be administered according to directions on the bottle.
_____Upset Stomach
(Pepto Bismol)
_____Diarrhea
(Imodium AD)
_____Poison Ivy
(Calamine Lotion or Cortaid)
_____Headache
(Tylenol)
or
_____My child is allergic to the following medications: ________________________________________
_____If my child forgets or loses his/her sunscreen or bug spray, the camp has my permission to apply any
sunscreen or bug spray deemed necessary.
Please list your child/ren’s names below:
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
Parent Signature
Date

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