FORM 2 Physician Signature Required
Recommendations for Licensed Medical Personnel
Bring this form to Registration
on the first day of Camp
To Parents/Guardians: Complete this section and give this form (Form 2) and a copy of your completed
Camper Health History Form (Form 1) to your child’s health care provider for review.
Dates will attend camp: from ________________________ to ______________________
Month/Day/Year
Month/Day Year
Camper Name: _________________________________________________________________________
First
Medical Personnel: Please review the CAMPER HEALTH
HISTORY FORM (FORM 1) and complete all remaining sections
of this form (FORM 2). Attach additional information if
needed.
□Male
Month/Day/Year
Weight __________lbs Height _______ft ______in
Blood Pressure _____________/______________
Last
□Female Birth Date _____________________Age on Arrival at Camp ___________
Month/Day/Year
Camper home address: __________________________________________________________
Physical Exam done today □Yes □No
(If “No”, date of last physical: _____________________
ACA accreditation standards specify physical exam within the
last 12 months.
Middle
City
State
Zip Code
Custodial parent/guardian phone: ( ______)______________________ (_______)____________________
This is an individual standing order for common over the counter medications. Physician’s signature on
this form indicates the camp nurse will be authorized to administer according to the Over the Counter
package directions and the camp’s medical protocol on an “As Needed” (PRN) basis. Medical Personnel:
Cross out those items the camper should not be given.
HR ____________ Resp ___________ Temp ___________
HEENT __________ Cardiac ____________ Lungs ________
Neuro___________ ABD __________ Spine ____________
Skin ____________Extremities _____________
Diet: ______________________________________________
Allergies:___________________________________________
Treatments or Conditions: _____________________________
___________________________________________________
Comments:
List any Current Prescription Medications and Over the
Counter Medications that the camper is scheduled to take
while at camp. These medications must be brought to camp
in original containers with original labels and include the
camper’s name (including vitamins and topical medicines).
Medication
Benadryl
Tylenol
Ibuprofen
Sudafed PE
Claritin
Robitussin
Musinex
Pepto Bismol
Mylanta
Tums
Milk of Magnesium
Imodium
Stool Softener
Hydrocortisone Cream
Topical Antibiotic Cream
Topical Antifungal Cream
Generic Allergy Eye Drops
Generic Cough Drops
Chloraseptic Throat Spray
Lice Shampoo
Reason/Indication
per label
per label
per label
per label
5-10mg
per label
per label
per label
per label
per label
per label
per label
per label
topical
topical
topical
1-2 drops
1 lozenge
1-2 sprays
per label
Dose
Q4-6 hrs prn
Q 4-6 hrs prn
Q 4-6 hrs prn
Q 6 hrs prn
Q 24 hrs prn
Q 4 hrs prn
per label instructions
per label instructions
per label instructions
per label instructions
per label instructions
per label instructions
apply to skin
Q 8-12 hrs prn
Q 6-8 hrs prn
Q 4-6 hrs prn
Q 2 hrs prn
Q 2hrs prn
per label instructions
Route
Allergies
Pain or Fever
Pain or Fever
Congestion/Sinus Pain
Allergies
Cough/Congestion
rash, itching, irritation
minor skin wounds
skin fungal rash
red, itchy eyes
cough, sore throat
sore throat, mouth pain
When Taken
I certify that I have performed a physical exam on the above named camper within the past 12 months and reviewed the Health History Form 1 and it is my medical
opinion that he/she is physically and emotionally able to engage and participate in all camp activities. Any exceptions or comments listed on the line below. I hereby
authorize Camp Sumatanga’s licensed nurses and health care staff to administer the above medications/treatments as indicated according to Sumatanga’s medical
protocol.
Comments: _____________________________________________________________________________________________________________________________
Physician’s Signature _____________________________________________________________________Date ____________________________________________
Practitioner’s Printed Name _______________________________________________________________ License # ________________________________________
Address _______________________________________________________________________________ Phone # _________________________________________