ࡱ> 796#` bjbj q $ CEEEEEE$zhi}}}i~}vC}C BLuֵfC0xYxx(Z@V4ii }}}}   STATE PROCEDURES REGARDING MEDICATIONS Campers must surrender all medication, EVEN OVER-THE-COUNTER MEDICATION (i.e.Tylenol, Advil, etc) to our Medical Staff at check-in, to be placed in a locked medical box for the duration of the camp. Campers may self-administer prescribed medications when needed with documented parental and authorized prescriber permission. Prescription medications must be in pharmacy prepared containers and labeled with the name of the child, name of the drug, strength, dosage, frequency, authorized prescriber or dentists name and date of the original prescription. Overthe- counter medication must be in the original container and labeled with the childs name. I hereby request that the following medication be self-administered by: ___________________________________________________, during Camel Lacrosse Camp. (PLEASE PRINT CAMPERS NAME) (DATE) I understand that I must supply the youth camp with the prescribed medication in its original containerand properly labeled by a physician/pharmacist. Over the counter medication shall be labeled with thechilds name by the Parent/Guardian(s) at check-in. I understand that this medication will be destroyedif not picked up within (1) week following the end of this session of camp. Name of Medication:______________________________________________________________ Times of Administration:_____, _____, _____ Dates of Administration: ___/___/___ to ___/___/___ Is this a controlled drug?__________________ Authorized Prescriber or Dentist Information: Name (PRINT):_________________________________ Phone #:_____________________________ Street Address:____________________________ City/Town:______________________ State:_____ Authorized Prescriber or Dentist Signature:________________________________________________ Parent/Guardian(s) Name (Printed):____________________________ Parent/Guardian(s) Signature:_________________________________ Relationship to child:________________________________ Phone Number:___________________ THIS SIDE TO BE FILLED OUT BY CAMP STAFF ONLY! Name of Child:____________________________________________________ Room #:_________ Group:_________________________ Coach: ________________________________________ Medication Name:_________________________________________________________ Date:___/___/___ Time:_____ AM/PM Dosage:_____ Strength:______ Trainer:______ Comments:_______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Medication Name:_________________________________________________________ Date:___/___/___ Time:_____ AM/PM Dosage:_____ Strength:______ Trainer:______ Comments:_______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Medication Name:_________________________________________________________ Date:___/___/___ Time:_____ AM/PM Dosage:_____ Strength:______ Trainer:______ Comments:_______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Medication Name:_________________________________________________________ Date:___/___/___ Time:_____ AM/PM Dosage:_____ Strength:______ Trainer:______ Comments:_______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Medication Name:__________________________________________ Date:___/___/___ Time:_____ AM/PM Dosage:_____ Strength:______ Trainer:______ Comments:_______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 'No / 8 K M q h3:hCJaJh5CJ8\aJ8hhCJaJhh5 h5\hh5CJ$\aJ$'\ M q r D E V Jh 7$8$H$gdhP+u U6[; V 7$8$H$gd50P:p/ =!"#$% 8 00P:p/ =!"#$% @@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No List 7 '\MqrDEV Jh P + u U 6   [ ; V0000000000000000000000000000000000000000000000000000000'\rEV Jh P + u U 6   [ ; V0000000000000000000000000000000000000000000000 h '(,V)J*O+DO,N  =*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType9*urn:schemas-microsoft-com:office:smarttagsplace p{U_SZ<F\cL\^dffh!#mo  X Z : < y { > @ " _ a 3333333333333333333333333333tt127KLMpq??CD3:o B@`]g@@UnknownGz Times New Roman5Symbol3& z Arial"qhrfrf_ _ !24d2KP)?2&STATE PROCEDURES REGARDING MEDICATIONSdcornelldcornellOh+'0 $0 P \ ht|(STATE PROCEDURES REGARDING MEDICATIONS dcornellNormal dcornell1Microsoft Office Word@@Jյ@dֵ_ ՜.+,0 hp|   'STATE PROCEDURES REGARDING MEDICATIONS Title  !"#$%'()*+,-/0123458Root Entry Fpauֵ:Data 1TablexWordDocumentq SummaryInformation(&DocumentSummaryInformation8.CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q