CC Medication Administration

Student Information

Student First Name

Student Last Name

Birthdate

Gender

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Please list all allergies/medical conditions.

Medically Necessary Medication

Please select one:

My child has medically necessary medication(s) that will require administration by authorized camp staff.

My child does not have any medically necessary medications that need to be administered while at camp.

Please list the NAME, DOSE, ROUTE, FREQUENCY, and any pertinent INFORMATION for Medication #1.

Please list the NAME, DOSE, ROUTE, FREQUENCY, and any pertinent INFORMATION for Medication #2.

Please list the NAME, DOSE, ROUTE, FREQUENCY, and any other pertinent INFORMATION for Medication #3.

Please list the NAME, DOSE, ROUTE, FREQUENCY, and any pertinent INFORMATION for Medication #4.

MEDICATION POLICY
All medications—prescription or over-the-counter—must be turned in upon checking in for Community Camp the morning of Monday, July 13. Medications must be provided in their original, clearly labeled containers. Prescription medications must include the pharmacy label with medical orders and the prescribing physician’s name. Medications not in their original containers cannot be accepted.
Please send only medically necessary medications with your child. Our Community Camp Nurse Crew maintains a supply of common over-the-counter medications and can administer these with your permission. Please do not pack over-the-counter medications unless they are medically required for your child.

I willfully consent for my child to receive the following medications if deemed necessary by the Community Camp Nurse Crew (please check all that apply):

BENADRYL FOR ALLERGIC REACTIONS

IBUPROFEN FOR PAIN OR FEVER

TYLENOL FOR PAIN OR FEVER

CLARITIN (NON-DROWSY ALLERGY MEDICATION)

ANTACID TABLETS

COUGH DROPS

Please SELECT ONE:

I give legal consent for Community of Faith Leadership to take my child to the local Emergency Room or Urgent Care if they deem it medically necessary to do so.

I DO NOT give legal consent for Community of Faith Leadership to take my child to the local Emergency Room or Urgent Care if they deem it medically necessary to do so.

Signature

COMMUNITY CAMP 2026 MEDICATION ADMINISTRATION FORM

Student Information

Medically Necessary Medication

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