If yes, please indicate the following.Carrier/Plan Name: Type a label Group & ID Number Type a label Carrier Address & Phone Number Name of Insured & Relationship to Camper Type a label
MEDICAL INFOName of Primary Doctor Type a label* Phone Number of Primary Doctor Type a label* Name of Dentist Type a label* Phone Number of Dentist Type a label*
Because the First Name Last Name requires medication during camp hours, I request that the medical staff at the Summer Manufacturing Institute be permitted to give this medication as directed below. I will provide the medication in an original pharmaceutically filled container whose label will clearly indicate the physician’s instructions for administration and physician’s name. I understand that the Summer Manufacturing Institute will not administer medications not listed on this form or in their original pharmaceutically filled container. Signature Medication Name(s): Dosage: Time(s) of Day to be Given: Possible Side Effects: Who will administer your prescribed medication?: Please Select I authorize and recommend self-medication by my child for the prescribed listed medication. I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending prescribed Epi-Pen (Epinephrine): Please Select I authorize and recommend self-medication by my child for the prescribed listed medication. I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending prescribed