Prescription Medication Form
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1Prescription Medication Form
Instructions: One form for each prescription medication and/or dosage, copy as needed. Place
this form and medication in ORIGINAL prescription bottle or vial, into a zip lock bag.
Camper's Name: ___________________________ Troop: _____ Campsite_______________
Address: ______________________________________________- Apt # ________________
City: ____________________________________________ ST: ______ ZIP: _____________
Name of Parent or Guardian: _______________________________ Phone: (
) __________
Work Telephone:(
) ________
Cell Phone: (
) ________
Doctor's name: ____________________________________________ Phone: (
) ________
Medication: _____________________________________ Strength: _____________________
Dosage and instructions: _________________________________________________________
Number of pills or Liquid Volume sent to Camp: _____________________________________
Reason for medication: __________________________________________________________
_____________________________________________________________________________
When was medication started: _______________ Temporary use [ ] or Permanent use[ ]
Side effects (reactions to foods, dehydration, stress, other medications, drowsiness, lethargy,
concentration, etc.):
______________________________________________________________________________
______________________________________________________________________________
_________________________________________________________________________-____
List other important information about this medication since access to medical information or
facilities could be delayed 6 - 10 hours, or more, due to remote wilderness settings:
______________________________________________________________________________
______________________________________________________________________________
Special Storage instructions: ______________________________________________________
______________________________________________________________________________
Expected action if medication is not taken as directed: __________________________________
______________________________________________________________________________
Waiver: This information is confidential and is provided to FSR Executive Staff ONLY, for the
express purpose of helping to ensure a healthy, safe camping experience for my child. This form
may be shared with medical personnel should the necessity arise. It will be returned to me at the
conclusion of this trip.
Signature of Parent/Guardian _____________________________________ Date: _________
(Revised 8/2007)
Page 40
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Parent category: Business