Microsoft word - swatara med form.doc

Cocalico School District Health Services
Medication Administration for Camp Swatara Experience
Below, please find a copy of the medication permission form for Camp Swatara. One form must be completed for
each medication your child is to receive at camp. If you need additional copies, contact the school nurses. If your
child will need to take medication during the experience, the following procedures must be used:
 All medications and permission forms must be brought to school on the morning of your child’s departure, even those students who currently have the same medication in school, i.e. inhalers, epi-pens, daily meds.  Only send the number of doses of medication necessary for the camp experience time.
 All medications must be in the original containers labeled from the pharmacy with the prescribing
information. In the case of inhalers, nasal sprays, they must be in the original box with the prescribing
information, have an accompanying note from your physician, or a physician’s signature on this form
with the dosage information clearly stated. No expired medication will be given.
 If it is necessary for your child to take an over the counter medication such as Tylenol, vitamins, Claritin, herbal or natural supplements, etc., you must have a prescription or note from the physician with the
child’s name, dosage and time to be given accompanying the medication. All medications must be in the
original containers.
 Students are not permitted to keep any medication with them in the camp. An exception to this may be inhalers and epi-pens with written permission to carry by the parent, physician and school nurse.
Students bringing medications to camp without the necessary information and signatures will not receive
those medications. If you have any questions concerning medication administration during the environmental
experience at Camp Swatara, please feel free to call the health room at your child’s school. Thank you for your
assistance in keeping all of our students healthy and safe.
I hereby grant permission for the nurse, or any person authorized by the school, to administer the medication listed below. If a medical necessity arises, the nurse may contact the prescribing professional to discuss this medication. Name of Child Date _________
__________ Student is competent to carry and self-administer yes no
Rescue Inhalers and epi-pens only
Date _________ __________________________________________________ Student is competent to carry and self-administer yes no
Signature of Physician
Rescue Inhalers and epi-pens only
Physician signature and instructions are required if your child is to
carry medication-rescue inhalers or Epi-pens only
For Camp Use Only

Source: http://www.cocalico.org/elem/Images/Swatara_med_form.pdf