Camp Medication Form - Camp Cayuga
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1
2FOR OFFICE USE ONLY:
Confirmed Meds
CAMP CAYUGA
Inaccurate: _____________
Health Record: __________
CAMP MEDICATION FORM
MARS:_________________
Data Base: _____________
JC or
TC
BUSINESS OFFICE: Camp Cayuga, PO Box 151, Peapack, NJ 07977 USA. (908) 470-1224, Fax: (908) 470-1228.
_______________________
SUMMER ADDRESS: Camp Cayuga, 321 Niles Pond Road, Honesdale, PA 18431. (570) 253-3133, Fax: (570) 253-3194.
Email: . Website:
LAST NAME (print):____________________________________. FIRST NAME:_________________________________.
:
Camper,
Staff Member.
Check One
or
Session:
Full Season,
First 6-Weeks,
Last 6-Weeks,
First-Half,
Second-Half,
Other:________________________________.
Mini-Sessions:
First 2-weeks,
Second 2-weeks,
Third 2-weeks,
Last 2-weeks.
INSTRUCTIONS: If your child is bringing medication to camp (prescription meds, over-the-counter meds, and vitamins), please refer to
your Parent Handbook, which explains the camp's policy about medications and packaging meds. Your child’s meds are to be placed
inside one clear plastic zip-lock baggie, labeled with your camper’s name and birth date. The Camp Medication Form is an inventory list of
the meds your child is bringing to camp. Complete this form at the time you package your child's meds for camp, and place it inside the
baggie with the meds. The meds you list on the Camp Medication Form must coincide with the meds inside the baggie. Do not mail this
form to us. Note: On the Health Examination Form, you are asked to list the meds your child is “currently taking” at the time you complete
the Health Form. The list of meds on the Health Form does not serve as an inventory list of meds your child will be bringing to camp.
Reminder: Do not send "gummy-type" vitamins/pills.
CHECK HERE IF MEDICATIONS ARE LISTED ON REVERSE SIDE.
NAME OF MEDICATION:
NAME OF MEDICATION:
(print)
(print)
_____________________________________________________.
_____________________________________________________.
CHECK
ALL BOXES THAT APPLY TO THIS MEDICATION.
CHECK
ALL BOXES THAT APPLY TO THIS MEDICATION.
Prescription medication.
Prescription medication.
Over-the-counter medication or
Vitamin.
Over-the-counter medication or
Vitamin.
Taken on a routine basis.
Taken on an as-needed basis.
Taken on a routine basis.
Taken on an as-needed basis.
Prescribed for a chronic illness or condition.
Prescribed for a chronic illness or condition.
EpiPen held on person.
Inhaler held on person.
EpiPen held on person.
Inhaler held on person.
STAFF ONLY:
The use (or non-use) of this med could impair my
STAFF ONLY:
The use (or non-use) of this med could impair my
ability to perform essential functions of my job.
ability to perform essential functions of my job.
Complete below as per original container’s label:
Complete below as per original container’s label:
Dosage:______________________________________________.
Dosage:______________________________________________.
Frequency:____________________________________________.
Frequency:____________________________________________.
Expiration Date:________________________________________.
Expiration Date:________________________________________.
Purpose:______________________________________________.
Purpose:______________________________________________.
_____________________________________________________.
_____________________________________________________.
Comments: ___________________________________________.
Comments: ___________________________________________.
NAME OF MEDICATION:
NAME OF MEDICATION:
(print)
(print)
_____________________________________________________.
_____________________________________________________.
CHECK
ALL BOXES THAT APPLY TO THIS MEDICATION.
CHECK
ALL BOXES THAT APPLY TO THIS MEDICATION.
Prescription medication.
Prescription medication.
Over-the-counter medication or
Vitamin.
Over-the-counter medication or
Vitamin.
Taken on a routine basis.
Taken on an as-needed basis.
Taken on a routine basis.
Taken on an as-needed basis.
Prescribed for a chronic illness or condition.
Prescribed for a chronic illness or condition.
EpiPen held on person.
Inhaler held on person.
EpiPen held on person.
Inhaler held on person.
STAFF ONLY:
The use (or non-use) of this med could impair my
STAFF ONLY:
The use (or non-use) of this med could impair my
ability to perform essential functions of my job.
ability to perform essential functions of my job.
Complete below as per original container’s label:
Complete below as per original container’s label:
Dosage:______________________________________________.
Dosage:______________________________________________.
Frequency:____________________________________________.
Frequency:____________________________________________.
Expiration Date:________________________________________.
Expiration Date:________________________________________.
Purpose:______________________________________________.
Purpose:______________________________________________.
_____________________________________________________.
_____________________________________________________.
Comments: ___________________________________________.
Comments: ___________________________________________.
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