Individual Medication Form - Custaloga Town Scout Reservation (Page 2 of 2) in pdf

French Creek Council

Boy Scouts of America

If a Scout or Scouter is using more that two medications, then please use additional forms

Waiver: This information is confidential and is provided to Health Officer or designee for the express purpose of

helping to ensure a healthy, safe camping experience for my child. This form may be shared with medical person-

nel should the necessity arise and will be part of your child’s medical record.

Signature of Parent/ Guardian ____________________________________________Date ________________

Administration of OVER THE COUNTER”OTC” Medication to Campers

RE: Administration of Medication's) to your child

We are delighted your son will be camping at French Creek Council Camp this summer! We would like to inform

you of the French Creek Council’s policy on medication at scout camp. This policy was developed to comply with

the National Standards of the Boy Scouts of America and the requirements of the Commonwealth of Pennsylvania .

Over the counter medications [known as “OTC”] could be administered to your child by our Camp Health Provider,

when requested, for these conditions:

Colds:

Robitussin DM, Throat Lozenges, Chloroseptic spray, Sudafed for daytime or

Dimetapp at bedtime

Sprains:

Tylenol or Ibuprofen (Motrin, Advil, Aleve)

Constipation:

Milk of Magnesia, Glycerin Suppository

Swimmer’s Ear:

Cortisporin Otic Drops

Diarrhea:

Pepto-Bismol or Imodium AD

Allergies:

Benadryl

Wounds:

Bacitracin ointment, Betadine

or other medications so recommended by our camp physician

Participants will NOT be charged for medications provided by the Health Lodge.

Custaloga Town Scout Reservation Medical Director and other Health lodge Staff reserve the right to make medical

decisions regarding the participation of individuals at camp.

It is a condition of your child’s attending camp that you grant permission to the Health Lodge Staff, to treat your

child for emergency or necessary health concerns. This may include providing these OTC medications listed above

to your child should they develop any of the above conditions or other medications as deemed necessary by the

camp physician.

Please sign below.

________________________________________________________________

________________________

Signature of Parent or Guardian

Date

If your child is allergic to any of the above listed OTC drugs or had other allergies, please sign below.

My son is allergic to: ________________________________________________________________________

COUNCIL POLICY ON PRESCRIPTION MEDICATION AT CAMP. To prevent problems with giving your child’s

medication, your child MUST have this form completed for any prescription medication with their BSA Health Form.

MEDICATION CAN NOT BE GIVEN TO YOUR CHILD ULESS THE CAMP IS IN RECEIPT OF THIS FORM.

Side 2

Custaloga Town Scout Reservation Individual Medication From

Revised 07/14/2004

Individual Medication Form - Custaloga Town Scout Reservation Page 2

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