Ymca Camp Zehnder Medication Procedure And Permission Form

2017 YMCA CAMP ZEHNDER

Medication Prodcedure & Permission Form

June 19, 2017 — September 1, 2017

Dear Parent / Guardian / Caretaker and Phyician:

Any medication, including all over-the-counter medication, administered by personnel of Camp Zehnder must be accompanied

by written orders from a physician. The medication must be in a labeled, prescription bottle with specific instructions.

(Pharmacies will provide bottles for camp use.) At NO time is a camper to transport or have in his/her possession any medication.

Camper’s Name: __________________________________________________________________ Birth Date: ________________________________________________

Address: ___________________________________________________________________________ Phone: ______________________________________________________

Parent Cell: ________________________________________________________________________ Group: _____________________________________________________

Physicians Authorization:

Medication: __________________________________________________________________________________ Dose: ______________________________________________

Time or circumstance of administration at camp: _________________________________________________________________________________________

Duration of administration: _____________________________________________________________________________________________________________________

Reason for administration: _____________________________________________________________________________________________________________________

Side effects to be aware of: ____________________________________________________________________________________________________________________

Any additional instructions or follow-up: __________________________________________________________________________________________________

Physician’s Signature: ______________________________________________________________________ Date: _____________________________________________

Parent / Guardian / Caretaker Permission:

Be advised that Camp Zehnder shall incur NO liability as a result of any injury arising from the administration of

medication and that the parents/guardians shall indemnify and hold harmless Camp Zehnder and its employees or

agents against any claims arising out of administration of this medication. I give permission to the health director

to administer the above medication to my child.

Parent/Legal Guardian Signature: ______________________________________________________ Date: _____________________________________________

THE COMMUNITY YMCA

Camp Zehnder

Here for all.

3911 Herbertsville Road

Financial assistance is offered based

Wall, NJ 08724

P. 732.836.9177

on availability of funds.

Ymca Camp Zehnder Medication Procedure And Permission Form - 2017