Camp Pisgah Medication Log Form

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Camp Pisgah Medication Log
Camper Name______________________________________________
Session:_________________________
Date:________________________
Allergies to any
Yes
No
List:
Medication?
Medication
Dosage-
Breakfast- 8:00 am
Lunch- 11:30 am/
Dinner:- 6:00 pm
Evening: 9:00 pm
as listed on
12:30 pm
prescription only!
1
2
3
4
5
6
EpiPen: Yes:_______ No:____________
Important Notice: By signing this, I understand that medicines will be given by Camp Pisgah staff member only if the above
infprmation is complete and in the original prescription bottle or OTC box with directions.
Parent/ Guardian Signature:____________________________________________________________
Sign Out:________________________________
Print Name
:__________________________________________________________________
________________________________
(from above)
1

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