We have indicated that our child, __________________________________________ will be using medication while he/she is attending St. Peter the Aleut Orthodox Summer Camp.
Please list below in the appropriate columns all Prescription and Over-the-Counter Medication information which the participant may require during the Camp:
Name of Medication
Times/Day: Given By:
(Please make a checkmark in the appropriate box.)
¨ I wish the asthma inhaler or epi-pen to be with my Youth Participant at all times.
¨ I wish the asthma inhaler or epi-pen to be kept with the Youth Retreat Health Officer/Nurse.
If a Youth Participant uses an inhaler to treat asthma, or carries an epi-pen:
Please Note! If this youth participant has your permission to self-medicate with any or all of the above described prescriptions or over the counter medications, or if a parent will be present and wishes to retain this responsibility, please clearly indicate above in the “Given By” Column. Otherwise, all listed medications will be collected at the beginning of the summer camp to be safely stored and administered by the Camp’s Designated Nursing Staff. All medications need to be brought to the camp and presented to Staff in original packaging and prescription bottles.
Signature of Parent/s or Legal Guardian/s