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Blue Ridge Mountains
Scout Reservation
Unit #: _______ Council: __________________________________ Date Attending Camp: _______________ Camper’s Name: ____________________________________________________________________________ Name of Parent or Guardian: ______________________________________ Phone: (____) _______________ Doctor’s Name: _________________________________________________ Phone: (____) _______________ Medication / Strength: _____________________________________________________________ Reason for medication: _____________________________________________________________ When was medication started? ________________________ Temporary: _____ Permanent: _____ Side effects (reactions to food, dehydration, stress, iodine, other medications, decreased balance,motor activity, concentration, drowsiness, lethargy, etc.): __________________________________ Special storage instructions: _________________________________________________________ Medication / Strength: _____________________________________________________________ Reason for medication: _____________________________________________________________ When was medication started? ________________________ Temporary: _____ Permanent: _____ Side effects (reactions to food, dehydration, stress, iodine, other medications, decreased balance,motor activity, concentration, drowsiness, lethargy, etc.): __________________________________ Special storage instructions: _________________________________________________________ Medication / Strength: _____________________________________________________________ Reason for medication: _____________________________________________________________ When was medication started? ________________________ Temporary: _____ Permanent: _____ Side effects (reactions to food, dehydration, stress, iodine, other medications, decreased balance,motor activity, concentration, drowsiness, lethargy, etc.): __________________________________ Special storage instructions: _________________________________________________________ Medication / Strength: _____________________________________________________________ Reason for medication: _____________________________________________________________ When was medication started? ________________________ Temporary: _____ Permanent: _____ Side effects (reactions to food, dehydration, stress, iodine, other medications, decreased balance,motor activity, concentration, drowsiness, lethargy, etc.): __________________________________ Special storage instructions: _________________________________________________________ Blue Ridge Mountains
Scout Reservation
Prescription Medication Card
Prescription Medication Card
Breakfast Lunch Dinner Evening Other: ________ Breakfast Lunch Dinner Evening Other: ________ Name: _________________________ Unit: ______ Name: _________________________ Unit: ______ City/State: _________________________________ City/State: _________________________________ Medications: _______________________________ Medications: _______________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Program:
Program:
Powhatan Ottari Claytor Fish Camp Mt. Man Powhatan Ottari Claytor Fish Camp Mt. Man Parent’s Signature: __________________________ Parent’s Signature: __________________________ Date: _________ Daytime Phone: _____________ Date: _________ Daytime Phone: _____________ Prescription Medication Card
Prescription Medication Card
Breakfast Lunch Dinner Evening Other: ________ Breakfast Lunch Dinner Evening Other: ________ Name: _________________________ Unit: ______ Name: _________________________ Unit: ______ City/State: _________________________________ City/State: _________________________________ Medications: _______________________________ Medications: _______________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Program:
Program:
Powhatan Ottari Claytor Fish Camp Mt. Man Powhatan Ottari Claytor Fish Camp Mt. Man Parent’s Signature: __________________________ Parent’s Signature: __________________________ Date: _________ Daytime Phone: _____________ Date: _________ Daytime Phone: _____________ Blue Ridge Mountains
Scout Reservation
AS NEEDED MEDICATION
AS NEEDED MEDICATION
(for example: Claritin, Tylenol, sinus medication) (for example: Claritin, Tylenol, sinus medication) Name: __________________________ Unit: _______ Name: __________________________ Unit: _______ City/State: ___________________________________ City/State: ___________________________________ Medication: ________________________________ Medication: ________________________________ Proper dosage is: ____________ every: ________ Proper dosage is: ____________ every: ________ Distribute as needed for: ______________________ Distribute as needed for: ______________________ __________________________________________ __________________________________________ Medication: ________________________________ Medication: ________________________________ Proper dosage is: ____________ every: ________ Proper dosage is: ____________ every: ________ Distribute as needed for: ______________________ Distribute as needed for: ______________________ __________________________________________ __________________________________________ PROGRAM: Powhatan Ottari Claytor Fish Camp
PROGRAM: Powhatan Ottari Claytor Fish Camp
Mt. Man High Knoll Voyageur New River Adventure Mt. Man High Knoll Voyageur New River Adventure Parent’s Signature: ___________________________ Parent’s Signature: ___________________________ Date: _________ Daytime Phone: ______________ Date: _________ Daytime Phone: ______________ AS NEEDED MEDICATION
AS NEEDED MEDICATION
(for example: Claritin, Tylenol, sinus medication) (for example: Claritin, Tylenol, sinus medication) Name: __________________________ Unit: _______ Name: __________________________ Unit: _______ City/State: ___________________________________ City/State: ___________________________________ Medication: ________________________________ Medication: ________________________________ Proper dosage is: ____________ every: ________ Proper dosage is: ____________ every: ________ Distribute as needed for: ______________________ Distribute as needed for: ______________________ __________________________________________ __________________________________________ Medication: ________________________________ Medication: ________________________________ Proper dosage is: ____________ every: ________ Proper dosage is: ____________ every: ________ Distribute as needed for: ______________________ Distribute as needed for: ______________________ __________________________________________ __________________________________________ PROGRAM: Powhatan Ottari Claytor Fish Camp
PROGRAM: Powhatan Ottari Claytor Fish Camp
Mt. Man High Knoll Voyageur New River Adventure Mt. Man High Knoll Voyageur New River Adventure Parent’s Signature: ___________________________ Parent’s Signature: ___________________________ Date: _________ Daytime Phone: ______________ Date: _________ Daytime Phone: ______________

Source: http://www.troop221bsa.org/assets/camp-med_forms.pdf