Medicine/Nurse Form: Camp Emmanuel 20__

 

Camper’s name______________________________________________________date of birth___________

 

Allergies (please include meds, food and others)     Med, food and other Reactions

 

___________________________________                       ___________________________________

 

___________________________________                        ___________________________________

 

___________________________________                        ___________________________________

 

___________________________________                        ___________________________________

 

___________________________________                        ___________________________________

 

___________________________________                        ___________________________________

 

___________________________________                        ___________________________________

 

 

We ____________________________ (parents name) give permission to the nurse that they can give this camper medication as needed (please mark the meds you are ok for the nurse to give. We will provide these meds.)

 

________Tylenol or acetaminophen 325 mg or 650mg every 4 hours for pain or fever

________ Advil or Ibuprofen 200 mg every 4 hours for pain or fever

________ Benadryl or diphenhydramine 25 mg every 4 hours for allergies, runny nose, sneezing,hives, insect bites or itchy skin

 

Please fill out med list on back of sheet even if you have pills in a pill box. Thanks

 

 

Name of Medication                    Dose      When     When     When     When     As

                                                 1 or 2 tabs       Break.        Lunch        Supper     Bedtime    Needed

 

_________________________  ______         ______    ______    ______   ______  _______

 

_________________________  ______         ______    ______    ______   ______  _______

 

________________________  ______         ______    ______    ______   ______  _______

 

________________________  ______         ______    ______    ______   ______  _______

________________________  ______         ______    ______    ______   ______  _______

________________________  ______         ______    ______    ______   ______  _______

________________________  ______         ______    ______    ______   ______  _______