Name (print): _________________________________________________________________ Medications & Parent/Guardian Permission PLEASE CAREFULLY READ THE FOLLOWING: If you disagree with any statements here, please cross out that section and initial it. Explain your wishes in the comment space provided. This medical form is correct so far as I know, and the person names in Section A has permission to participate in all camp activities except as noted on the form by me or on the reverse by the doctor. In case of accident, injury or illness while at camp, I hereby give my permission to the doctor selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery or injections of medications. I hereby request that the prescription medication(s) listed, ordered by a licensed practitioner for my child, be administered by the camp’s Health Officer. I understand that I must supply the camp with the prescribed medication in the original container as dispensed and properly labeled by a doctor or pharmacist and will provide no more than is appropriate for my child’s camp stay. I understand that this medication will be destroyed if not picked up within one week after my child leaves camp. I give my permission for the camp Health Officer to administer over-the-counter medications as directed for conditions as dictated by the Camp Physician (The Housatonic Council’s policy on medications at Scout Camp has been formulated to comply with the National Standards of the Boy Scouts of America and the State of Connecticut Health Dept.) Over the counter medications may include: Sunscreen, topically as needed for sun exposure; Bug Repellant, topically as needed q 2-4 hrs; Robitussin (Guifenesin), po, per weight/age dosing for cough without fever as needed q 6 hrs; Benadryl (Diphenhydramine), po, per weight/age dosing for rash/itch, insect bites, as needed, q 4-6 hrs.; Pepto-Bismol liquid or tablets, po, per weight/age dosing for upset stomach without fever, as needed; Clear, Liquid Non-salty Diet for diarrhea (i.e. Flat Non-diet Soda); Milk of Magnesia, po per weight/age dosing for constipation, as needed q 6 hrs (NOT more than 2 consecutive doses); Tylenol (Acetaminophen), po, per weight/age dosing for pain, burns, cold symptoms without fever, ear ache, headache, temperature without other symptoms, as needed q 4-6 hrs; Motrin (Ibuprofen), po, per weight/age dosing for pain, menstrual cramps as needed q 6-8 hrs; Saline Gargles, Cepacol Gargles or Throat Lozenge, po, 1 tab for sore throat q 2-4 hrs, for a sore throat without fever, as needed; Bacitracin, topically, for minor abrasions and superficial skin lacerations wound care/infection prevention, as needed; Cortaid ½ % or Benadryl Cream, topically for itch/contact dermatitis, as needed; Lotromin, for athletes foot, per directions on tube, as needed; Calamine Lotion, topically, for poison ivy, as needed, q 1 hr; Solarcaine or Liquid Aloe Vera, topically for mild sunburn, as needed; EPI Pen (Auto Inject) & Benadryl (po, per weight/age dosing), for Anaphylactic Reaction (911 transport to E.R. for medical evaluation and follow-up) Signature: ___________________________________________Date____________________ Adults over 18 sign here (Parent/Guardian signs for Camper) If parent/guardian, what is your relationship to scout___________________________________ Comment(s): __________________________________________________________________



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