Dahlemcenter.org

Parent/Guardian Request for Assistance
in Dispensing Medication to Camper
Some campers are able to attend camp only through the effective use of medication. If possible, all medications should be given under the supervision of the parent(s) or guardian(s). When this is not possible, The Dahlem Conservancy’s Summer Outdoor Adventure Day Camp staff may give prescribed medication(s) as an assistance to parents/guardians when the following conditions are met. ________________________________ ______ ____________________________________
Prescription medications must be in their original containers, bearing the pharmacy label, and have specific instructions for use (camper’s
name, dosage, # of pills inside, prescribing practitioner, pharmacy name and address, filler’s initials, serial #).
Medication #1: ________________________________________________ Dose: _________ Time to Administer: _______________
Reason for taking: ______________________________________________________________________________________ Side effects or special precautions: _________________________________________________________________________ Medication #2: ________________________________________________ Dose: _________ Time to Administer: _______________ Reason for taking: ______________________________________________________________________________________ Side effects or special precautions: _________________________________________________________________________ Medication #3: ________________________________________________ Dose: _________ Time to Administer: _______________ Reason for taking: ______________________________________________________________________________________ Side effects or special precautions: _________________________________________________________________________
Over-the-counter medications must be in their original containers, containing the original label and directions for use. In addition,
these must be labeled with the participant’s name and the dosage. Parents/Guardians must supply the camp with any medications.
Medication #1: ________________________________________________ Dose: _________ Time to Administer: _______________
Reason for taking: ______________________________________________________________________________________ Side effects or special precautions: _________________________________________________________________________ Medication #2: ________________________________________________ Dose: _________ Time to Administer: _______________ Reason for taking: ______________________________________________________________________________________ Side effects or special precautions: _________________________________________________________________________
Asthma - list each medication separately above. All must have the pharmacy labels! Sign the relevant statement below:
 The camper does not need to have the inhaler with him/her at all times and the medication shall be stored in the office (OF) and
Parent/Guardian Signature: ___________________________________________(OF)
 The camper should have the medication(s) with him/her at all times in his/her pack (CP). Note: Camp staff must monitor each Parent/Guardian Signature: ____________________________________________(CP)
 If a spacer or nebulizer is used for asthma treatments, please note the type: ___________________________________________
Severe Allergy - list each medication separately above. All must have the pharmacy labels! Sign the relevant statement below:
Two Epipens should be brought to camp. The camper must be trained in the use of the Epipen.
 The camper does not need to have medication(s) with him/her at all times and the medication shall be stored in the office (OF) and administered as needed. Circle which medication(s): Benadryl, Epipen Parent/Guardian Signature: ____________________(OF)
 The camper should have the medication(s) with him/her at all times in his/her pack (CP). Note: Camp staff must monitor each dose. Circle which medication(s): Benadryl, Epipen Parent/Guardian Signature: __________________________________(CP)
 If the Epipen is prescribed, does the camper recognize the onset of an allergic reaction so as to notify staff upon the occurrence of these symptoms? ___Yes ___No If no, contact the Dahlem office today.  Describe the past allergic reaction to each allergen (use the back of this form).

Source: http://dahlemcenter.org/files/Camp%20Dispensing%20Medication%202013.pdf