Microsoft word - standing orders and physical form09.doc

Camper Name: ____________________________________________ Date of Birth: ________________ This MUST be completed by a licensed PHYSICIAN and is REQUIRED for camper ATTENDANCE. Standing Orders: *Form must be filled out each year. Attention Physician: The following Over-the-Counter medications will be available in the Health Center. Administration of these medications is “per label directions” unless otherwise noted. Generic drugs may be used in place of name brands. Please check “yes” for medications the Site Medical Staff is allowed to administer to the camper, as needed. Acetaminophen: (discomfort/fever, headache, pain relief) Ibuprofen: (discomfort/fever, menstrual cramps, headache, muscle aches) Hydrogen Peroxide/Antiseptic Solution (topical, wound cleaning) Bacitracin/Neomycin/Polymyxin (topical, antibiotic ointment) Calamine/Caladryl Lotion: (topical, skin irritation) Hydrocortisone Cream: (topical, skin irritation) Ivarest Cream (topical, skin irritation) Cepecol Lozenges: (throat irritation, cough) Robitussin: (cough suppressant, cough expectorant) Benadryl: (topical for skin irritation, oral for allergies/allergy, cold symptoms) Sudafed: (allergies/allergy symptoms, sinus, cold symptoms) Mylanta: (heartburn, acid indigestion, sour stomach, gas) Tums: (heartburn, sour stomach, acid indigestion, upset stomach) Pepto-Bismol: (nausea, heartburn, indigestion, upset stomach, diarrhea) All PRESCRIPTION and any additional OVER-THE-COUNTER medications: (Attach sheets as necessary) * MEDICATIONS MUST BE IN ORIGINAL CONTAINERS * **A PHYSICIAN and PARENT/GUARDIAN SIGNATURE are required in order to allow the Site Medical Staff to administer ANY and ALL medications checked YES. Date of Standing Orders: ________________ Signature of PHYSICIAN: ______________________________________ Printed Name__________________________________________________ Signature of PARENT/GUARDIAN: ______________________________________ Date: _______________ Print Name of Parent/Guardian: ____________________________________________ Aldersgate and Casowasco thank you for your cooperation. Both sites are ministries of the North Central NY Conference of The United Methodist Church (Determines fitness to engage in strenuous camping activities) The examination must be within 24 months (2 years) of the child’s entire stay/time at camp. ** If there is a copy of a physical from the child’s Physician, Health Clinic, School or Sports Physical, please attach.** **If no physical examination is attached, PHYSICIAN must complete this form for child to attend camp session.** Camper Name: ____________________________________________ Date of Birth: ________________ Allergies: (please specify) __________________________________________ General Appraisal: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Special Considerations: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Restrictions while attending camp: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Other: _____________________________________________________________________________________________ _____________________________________________________________________________________________ I have examined the person herein described and it is my opinion that the individual is physically able to engage in all camp activities, except as noted above. Date of Physical Exam: ________________ Signature of PHYSICIAN: _____________________________________ Printed Name_________________________________________________ Aldersgate and Casowasco thank you for your cooperation. Both sites are ministries of the North Central NY Conference of The United Methodist Church


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