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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.
Drug Name
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- Physician
Please document below the patient’s current medication regime for both scheduled and “as needed” medications routinely received by the above noted minor.
Prescribed Medication
Schedule *Be Specific*
Comments
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)
Comments:__________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ 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: _____________________________________________________________________ Parent Signature: ___________________________________________________________________Date:___________________________

Source: http://www.nyclabschool.org/ourpages/auto/2013/9/9/36186960/Medication-self%20carry%20form.pdf

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