WINTER (Until May 15th)
SUMMER (After May 15th)
4 New King St Ste.130, White Plains, NY 10604 MEDICATION FORM 2014
Please fill this form out for our Health Center, regardless if you have registered with CVS/pharmacy for distribution of your child’s daily medications. As a reminder, all medications that are prescription medications must be registered with CVS/pharmacy for packaging. If your son needs any over-the-counter medications while at camp, we will supply them for him. Camper’s Name ________________________________________________________________ Date of Birth ____________________
I give permission for Camp Mah-Kee-Nac to administer over-the-counter medications to my son if the nurse deems it necessary.
The following is a partial list of basic over-the counter medications stocked in our Health Center so there is no need to send
any of them to camp: Tylenol, Motrin, Pepto Bismol, Tums, Imodium AD, Mylanta, Imodium AD, Calamine Lotion / Anti-Itch Gel, Cortaid, Tinactin, Solarcaine, Benadryl, Sudafed, Robitussin, Robitussin DB and Dramamine.
Parent/Guardian signature: _________________________________________________________________
q My child takes no daily medication
q My child takes daily medication, daily vitamins/nutritional supplements, and/or uses an inhaler and I have registered with CVS/
q My child takes PRN (as needed) medication and I have registered with CVS/pharmacy (this includes inhalers, allergy medicine, ointments, nose sprays, eye drops, and liquids) SCHEDULE OF DAILY AND PRN(AS NEEDED) MEDICATIONS THAT WILL BE SUPPLIED BY CVS/PHARMACY:

Bkfst/Wake up: ______________________________ ____________________ ___________________ q PRN q Daily8-9 AM ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily ______________________________ ____________________ ___________________ q PRN q Daily Name of Prescribing Physician ___________________________________________ Phone _________________________________ Address / City / State / Zip ________________________________________________________________________________________ I hereby authorize Camp Mah-Kee-Nac to administer the above listed medications to my child as directed. SIGNATURE OF PARENT OR GUARDIAN ___________________________________________________________________________


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