Clarkson University Summer Youth Programs
Clarkson University Summer Youth Programs
Parent/Guardian and Health Care Provider’s Individualized Orders Authorization
Individualized Orders for: ______
participant’s name
DOB: ______HEIGHT: ______WEIGHT: ______
Program: Dates of Camp Attendance: ______.
IMPORTANT: The over-the-counter drugs listed below are available to summer program participants and are retained and monitored by Clarkson’s Summer Youth Programs Medical Staff. As defined by NYS DOH, these medications should not be brought from home or retained by the camper. In order to dispense such medications, parents/guardians AND the health care provider need to sign the form indicating agreement with the prescribed level of over-the-counter medication for your child. Circle “Yes” for the medications you will allow your child to receive. Circle “No” for whichever ones you do not want him/her to receive. This form must be returned even if you do want your child to receive any medications. Medications will NOT be dispensed without this form on file.
Drug Name / Preferred Route(circle preferred formulation if applicable) / Dosage / Schedule & Indications (not to exceed recommended daily dose) / Authorization? / Comments
Tylenol / PO
(chewable tabs, elixir, tabs) / Per label instructions by age/weight / Q4hr prn, for pain or fever >____°F / Yes No
Ibuprofen / PO
(chewable tabs, suspension, tabs) / Per label instructions by age/weight / Q4-6hrs prn, for pain or fever >____°F / Yes No
Benadryl / PO
(elixir, chewable tabs, pills) / Per label instructions by age/weight / Q6hr prn for allergic reaction / Yes No
Children’s Mylanta / PO
(chewable tabs) / Per label instructions by age/weight / BID-TID prn for stomach upset / Yes No
Dramamine / PO
(chewable 50mg tab) / Per label instructions by age/weight / Q6-8hrs prn for motion sickness / Yes No
Dimetapp / PO
(exlier, tabs) / Per label instructions by age/weight / Q6-8hrs prn for nasal congestion/ drainage / Yes No
Midol / PO
(caplets, tabs) / Per label instructions by age/weight / Q6hr prn for menstrual cramping and discomfort / Yes No
Pepto-Bismol / PO
(liquid, chewable tabs) / Per label instructions by age/weight / Q30min – 1hr, prn for diarrhea / Yes No
Robitussin / PO
(syrup) / Per label instructions by age/weight / Q4hr prn, for cough / Yes No
Tums / PO
(tablet) / Per label instructions by age/weight / Q1hr, prn for upset stomach related to indigestion / Yes No
FORM CONTINUED ON NEXT PAGE
Clarkson University Summer Youth Programs
Parent/Guardian and Health Care Provider’s Individualized Orders Authorization
PAGE 2
Please list any medications your child takes (prescription and over-the-counter) and will be bringing to camp. Include both “scheduled” and “as needed” medications. These medications must be kept in their original packaging/bottle that identifies the name of the medication, the dosage, the frequency of administration, and the prescribing doctor (if applicable).
Drug Name / Route / Dosage / Schedule & Indications / Reason / CommentsHealth Care Provider Authorization:
Health Care Provider Name: ______Phone#: ______
Address: ______License#: ______
Health Care Provider Signature: ______Date: ______
Parent/Guardian Authorization:
I give permissions for my child, ______, to receive the medication(s) as prescribed above by our licensed health care provider. Over-the-counter medications selected will be provided by Clarkson University Summer Youth Programs Medical Staff. The prescribed medications listed are to be provided by me in the properly labeled original container from the pharmacy. I understand that my child will have medications administered to them by the Clarkson University Summer Youth Programs Medical Staff. I understand that all medications must be turned in to the Clarkson University Summer Youth Programs Medical Staff, with the exception of severe medical condition authorizations, such as the use of Epi pens, rescue inhalers, and/or other medications at the discretion of the Medical Staff. Parents will be notified and campers will be sent home if they are found in possession of any medication without proper authorization.
Parent/Guardian Signature: ______Date:______
ALL CAMPERS MUST HAVE THIS FORM COMPLETED AND ON FILE TO STAY AT CAMP