Permission To Treat Form printable pdf download

Permission To Treat Form

PERMISSION TO TREAT FORM

I, __________________________, give Camp Berger’s health designee permission to provide routine

health care (first aid/CPR), procedures according to the Health Procedures attached.

I understand that all necessary precautions will be taken by Camp Berger for the safety of my child/ren and

that I will be contacted in the case of emergency. Please initial is the space provided.

Please list your child/ren’s names below:

_________________________________________

__________________________________________

_________________________________________

__________________________________________

_________________________________________

__________________________________________

Parent Signature

Date

I, __________________________, hereby give Camp Berger’s health designee permission to administer

the following over-the-counter medications if the site director deems it necessary.

Dosages will be administered according to directions on the bottle.

_____Upset Stomach

(Pepto Bismol)

_____Diarrhea

(Imodium AD)

_____Poison Ivy

(Calamine Lotion or Cortaid)

_____Headache

(Tylenol)

_____My child is allergic to the following medications: ________________________________________

_____If my child forgets or loses his/her sunscreen or bug spray, the camp has my permission to apply any

sunscreen or bug spray deemed necessary.

Please list your child/ren’s names below:

_________________________________________

__________________________________________

_________________________________________

__________________________________________

_________________________________________

__________________________________________

Parent Signature

Date

Permission To Treat Form