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Frost Valley YMCA Wellness Center2000 Frost Valley Road, Claryville, NY 12725Ph: (845)985-2291 Fax: (845)985-0059 FrostValley.org
Written Doctor and Parent Permission Form
please note: All medications, vitamins, supplements, or topical treatment require
written permission from a physician and parent
Camper Last Name_____________________________________________First Name______________________________________
D.O.B ___________________________________ Weight______________Allergies________________________________________
Physician’s name: ______________________________________________Phone #________________________________________
The following over the counter medications are available in the health center. It is not necessary to send these medications with the
students. These medications can be administered by a Registered Nurse per label instructions by age and weight only if Parent and
Physician signature is documented below. Note: All medications must be sent in original packaging.
Schedule and Indications
To be adminis-
tered if needed
Q 4h as needed for pain or fever>___-F
Q 6h as needed for pain or fever>___-F
(chewable tabs, elixir, suspension or tabs)
Q 4h nasal congestion *not more than 4 doses in 24
Q 6 h as needed for allergic reaction, hives, insect
30 minutes prior to sun exposure as needed for out-
Please document below the patient’s current medication regime for both scheduled and “as needed” medications routinely received by the above noted minor.
Schedule *Be Specific*
Self-carry medication release for Sun block, Rescue inhalers, epi–pens and insulin pumps
We request that the above named camper/student be permitted to carry one or all of the following:
(Please check all that apply and indicate MD order above
The above noted ‘self-carry” items/medications are permitted for the indicated minor at all times. He/She has been instructed by the physician and
parents and acknowledges the proper understanding of the purpose, frequency and appropriate method of use of these items.
As I consider him/ her responsible, I will not hold Frost Valley YMCA personnel responsible for any errors which may arise in my child’s self
administration of these items/medications.
MUst HaVe tHe FolloWInG sIGnatURes oR no oVeR tHe CoUnteR, pResCRIptIon oR selF-CaRRY MeDICatIons Can Be aDMInIsteReD at CaMp
Physician /Health Care providers Signature:
Phone #_______________________________Address: _____________________________________________________________________
Treatments for Type 2 Diabetes The 'first-line' treatment for Type 2 diabetes is diet and exercise. If your blood glucose level remains high despite a trial of diet and exercise, then tablets to reduce the blood glucose level are usual y advised. Insulin injections are needed in some cases if the blood glucose level remains too high despite taking tablets. Treatments for other related prob
Drugs on Tap: What’s In Our Tap Water? Here’s a question to ponder. What happens to the hundreds of millions of prescription drugs and the over-the-counter medications that are swallowed daily? The answer: they go out through the plumbing. Being flushed down the toilet and into the sewage system, 90 per cent of every drug swallowed is either excreted, totally unchanged, or is