Yorktown Parks & Recreation
Summer Day Camp Program
Medication Permission Form
Dear Parent/Guardian,
Any camper or staff member needing to take/possess medication during the camp day
must submit and have on file a completed “Medication Permission Form”.
Please use the “Yorktown Parks & Recreation Summer Day Camp Medication
Permission Form”. School forms are not valid. You and your child’s prescribing Doctor
must sign this form.
There are two (2) forms – one (1) for Medications and Self Administration, and one (1) for
Epi-Pen/Inhalers. Permission is needed for over the counter (OTC) medications that are
prescribed by physician (ex. Benadryl). Please fill out the appropriate form.
Please remember that all medication must be current and in its original package or
prescription bottle.
Please be sure to bring all medications and completed form on the First day your child
attends camp. Campers will not be able to participate in camp without appropriate form
on file. If needed, Camp Directors can withdraw campers from groups without medical
forms.
All medicine should be provided in the following manner:
o Placed in a Ziploc bag in its original container
o Include child’s name and photograph
o If your child is to carry his/her own medication, please make sure it is clearly
labeled and easily accessible.
Medication should be picked up on the campers last day of camp. After camp ends all
medications can be picked up at the Parks & Recreation Office. All medicines not picked
up will be discarded by September 1st.
Thank you. We look forward to a safe and healthy summer!
Sincerely,
Christopher Soi
Assistant Superintendent
Yorktown Parks & Recreation
Yorktown Parks & Recreation – Summer Day Camp Program
PERMISSION FOR MEDICATION & SELF ADMINISTRATION
As outlined in the Children’s Camps Safety Plan Guide Secion IV Part C- Medication must be self administered
NAME OF CAMPER __________________________________ DATE OF BIRTH _________
Full address ________________________________________________________________________
Home Phone ______________________ Campsite Attending ______________________________
Mother’s Name ____________________ Day Time # _________________ Cell _______________
Father’s Name _____________________ Day Time # _________________ Cell _______________
Emergency Contact ______________________ Phone # ________________ Relation ___________
MEDICAL INFORMATION
Physician Name _________________________ Physicians Phone ________________________
Health Insurance Carrier ______________________________ Policy Number _________________
MEDICATION DOSAGE WHEN TO ADMINISTER
All medication must be in original container with original prescription label and have current date of expiration.
Any Additional Information: ___________________________________________________________
__________________________________________________________________________________
_______ I request that my child’s prescription medication be securely stored in the camp office under the
supervision of the camp staff. I certify that my child has been instructed and is capable of proper self administration
of the medication.
_______ I request that my child be permitted to carry his/her prescribed medication at camp. I certify that my child
has been instructed and is capable of proper self administration of the medication. My child has been instructed
not to take the medication without medical designee present. I understand that if my child is using this medication
unsafely, irresponsibly or fails to keep it out of reach from other campers, he/she will be taken to the camp office
immediately and a call to the parent/guardian will be placed. I understand that the Town of Yorktown Parks &
Recreation Department is not responsible for lost, stolen or improperly discharged medication
.
I give permission to the onsite medical designee to seek emergency treatment at a hospital emergency room
and to observe the above named camper while self-administering the above mentioned medication(s).
______________________________ ______________________________ _____________
Signature of Parent/ Guardian Printed Name of Parent/Guardian Date
______________________________ ______________________________ _____________
Signature of Child’s Physician Printed Name of Child’s Physician Date
Yorktown Parks & Recreation – Summer Day Camp Program
PERMISSION FOR PRESCRIPTION EPI-PEN and/or INHALER
NAME OF CAMPER __________________________________ DATE OF BIRTH _________
Full address ________________________________________________________________________
Home Phone ______________________ Campsite Attending ______________________________
Mother’s Name ____________________ Day Time # _________________ Cell _______________
Father’s Name _____________________ Day Time # _________________ Cell _______________
Emergency Contact ______________________ Phone # ________________ Relation ___________
MEDICAL INFORMATION
Physician Name _________________________ Physicians Phone ________________________
Health Insurance Carrier ______________________________ Policy Number _________________
TO BE COMPLETED BY PHYSICIAN or PRESCRIBED LICENSED HEALTH CARE PROVIDER
All medication must be in original container with original prescription label and have current date of expiration.
CHILD'S DIAGNOSIS_________________________________________________________________
MEDICATION NAME______________________ Dosage ____________Frequency ______________
MEDICATION NAME______________________ Dosage ____________Frequency ______________
If medication is to be given “when needed,” please circle indications
1. Swelling of lips, tongue,
throat and or around the eyes
2. Difficult swallowing
3. Tightness in chest and or
difficulty breathing
4. Shortness of Breath
5. Sever cough or wheezing
6. Itchiness around the mouth
7. Itchiness all over body
8. Rash (Hives):
9. Other __________________
Action to be taken? ____________________________________________________________
How soon may it be repeated? ___________________________________________________
Additional information __________________________________________________________
____________________________________________________________________________
_______ I request that my child’s prescription epi-pen or inhaler be securely stored in the camp office under the
supervision of the camp staff. I certify that my child has been instructed and is capable of proper self administration
of the medication.
_______ I request that my child be permitted to carry his/her prescribed epi-pen or inhaler at camp. I certify that
my child has been instructed and is capable of proper self administration of the medication. I understand that if my
child is using this medication unsafely, irresponsibly or fails to keep it out of reach from other campers, he/she will
be taken to the camp office immediately and a call to the parent/guardian will be placed. I understand that the
Town of Yorktown Parks and Recreation is not responsible for lost, stolen or improperly discharged medication
.
I give permission to the onsite medical designee to seek emergency treatment at a hospital emergency room
and to observe the above named camper while self-administering the above mentioned medication(s).
______________________________ ______________________________ _____________
Signature of Parent/ Guardian Printed Name of Parent/Guardian Date
______________________________ ______________________________ _____________
Signature of Child’s Physician Printed Name of Child’s Physician Date
