Individual Medication Form - Custaloga Town Scout Reservation
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1
2French Creek Council
Boy Scouts of America
French Creek Council – Boy Scouts of America
Who should use this form?
Any Scout or Scouter (adult) coming to
MEDICATION INFORMATION FORM
Camp.
Individual Form for Custaloga Town Reservation
What do I do with this form?
All medications must be in the original pharmacy container with
Turn it in, with your physical and any
patient’s name, drug and dosage clearly marked including any
medication your are bringing, to the
“over the counter” medications
Health Lodge
1.
Camper’s Name ___________________________________________________________________________________________
Name of Parent/Guardian ____________________________________________________________________________________
Phones: Home (____)___________________Work (_____)___________________Cell (_____)_____________________________
Doctor’s Name___________________________________________________ Dr’s. Phone(_____)__________________________
Allergies:________________________________________________________________
Time
S
M T W T
F
S
Medication Name_________________________________________________________
Strength and Method of Administration________________________________________
Dosage____________________________ Storage Instructions____________________
Total Quantity Needed ________________Quantity Sent to Camp __________________
Reason for medication_____________________________________________________
Relevant Side Effects to be observed, if any: (reactions to food, dehydration, stress, hives,
other meds, decreased balance, ore activity, concentration, drowsiness lethargy, etc.)
_________________________________________________________________________
List other important information about this medication since access to medical information or facilities could be delayed up to 3-4 hours
due to wilderness setting.____________________________________________________________________________________
Expected action if medicines is not taken as directed_______________________________________________________________
2.
Camper’s Name ___________________________________________________________________________________________
Name of Parent/Guardian ____________________________________________________________________________________
Phones: Home (____)__________________________Work (_____)___________________Cell (_____)______________________
Doctor’s Name________________________________________________________ Dr’s. Phone(_____)_____________________
Allergies:__________________________________________________________________
Time
S
M T W T
F
S
Medication Name___________________________________________________________
Strength and Method of Administration__________________________________________
Dosage________________________ Storage Instructions__________________________
Total Quantity Needed ____________ Quantity Sent to Camp _______________________
Reason for medication_______________________________________________________
Relevant Side Effects to be observed, if any: (reactions to food, dehydration, stress, hives,
other meds, decreased balance, ore activity, concentration, drowsiness lethargy, etc.)
_______________________________________________________________________
List other important information about this medication since access to medical information or facilities could be delayed up to 3-4 hours
due to wilderness setting._______________________________________________________________________________________
Expected action if medicines is not taken as directed__________________________________________________________________
Shots of any kind may not be administered by camp staff.
Certain medications should be kept with the SCOUT/SCOUTER [EPI-PENs for bee or in-
sect bites due to allergic reactions; INHALERS for acute asthma actions;
or cardiac medications SUCH AS Nitroglycerin]
Do NOT turn these medications to the health lodge
Side 1
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