ALL CAMPERS (EXCEPT ABC CAMPERS) MUST HAVE A
PHYSICIAN/HEALTHCARE PROVIDER COMPLETE THIS
OVER-THE-COUNTER MEDICATIONS FORM
Dear Camp Families,
St. Crispin’s relies on medical volunteers to ensure the health of everyone at Summer Camp. For years, like
many camps, our biggest helpers were Registered Nurses. However, I was recently made aware of concerns
from the Oklahoma Board of Nursing that—under the system we were using—it was not appropriate for RNs to
dispense the over-the-counter medicines that we keep in stock in the Infirmary. Things like Pepto, Tylenol,
Benadryl, antibiotic ointment, and cough drops.
After learning this I had a few options (explained below):
1) Though RNs cannot administer from our stock of meds, they can administer meds that each camper brought
with them. This is how schools do it. This would mean that every camper would have to bring every possible
medicine that they might need at Camp. I decided that this option would be too much of a hassle for our parents,
too much of a confusion for our medical staff, and it ran the risk of a camper not being able to receive
appropriate care simply because they didn’t pack a certain medicine.
2) I can leave RNs off the list of possible medical volunteers and focus my search on Physician Assistants,
Nurse Practitioners, and doctors. It is within the scope of practice of these individuals to dispense the over-thecounter medicines we keep in stock. We did this last year and attempted it this year. However, after months of
searching this year I cannot find the number of individuals we need to fill this crucial role. Summer camp is
approaching too quickly to rely on this avenue.
This leaves the final option as the best option:
3) The final option that addressed the Board of Nursing’s concern is to have each camper visit a doctor before
coming to camp. The doctor will fill out a form which lists all medicines we keep in the Infirmary and will
indicate for each camper which medicines they may be allowed to take, for what reasons, and how. Having this
form on file for each camper will allow RNs to administer appropriate care for our campers.
I realize that summer is rapidly approaching and this adds an extra step for our already busy Camp families. I
have tried very hard to avoid this extra step for you. I hope you will agree, though, that we must be able to
provide the appropriate care for campers while they are here at Camp. This form enables us to do that.
If you have questions about this please contact me.
Thank you for your understanding. See you at Camp!
Daniel Chapman
Summer Camp Director
stcrispinsdirector@gmail.com
405-382-1619
Over-The-Counter Medications
Physicians Orders
36302 State Highway 9, Wewoka, OK 74884
Tel: 405-382-1619 Fax: 405-382-1631 Email: stcrispinsdirector@gmail.com
TO BE FILLED OUT BY PHYSICIAN/HEALTHCARE PROVIDER
CAMPER NAME: _________________________________________________DATE OF BIRTH: _______________
ALLERGIES:_____________________________________________________________________________________
FOOD SENSITIVITIES:___________________________________________________RECENT WEIGHT: ________
HEALTH CONDITIONS:___________________________________________________________________________
The following over-the-counter (OTC) medications are available in the Infirmary, and can be administered as needed per label
instructions by age and weight of the camper. PLEASE NOTE: Absolutely NO over-the-counter medications, supplements, vitamins,
or topical ointments can be administered by the camp Registered Nurse (RN), in accordance with the Oklahoma Board of Nursing
without a physician’s order.
PRESCRIPTION MEDICATIONS CAN BE GIVEN FROM THEIR ORIGINAL CONTAINERS WITH LABELING INTACT
TO THE PROVIDER: Please indicate approval for administration by circling YES or NO in the space indicated.
MEDICATION
ROUTE
DOSAGE
SCHEDULE & INDICATIONS
MAY BE
ADMINISTERED
Acetaminophen (Tylenol)
By mouth (elixir or tablets)
Per label instructions
By age and weight
Every 4 hours PRN headache, pain
or fever > 101 °F
Yes
No
Ibuprofen (Motrin)
By mouth (elixir, suspension
or tablets)
Per label instructions
By age and weight
Every 4 hours PRN headache, pain
or fever > 101 °F
Yes
No
Naproxen sodium
By mouth (tablets)
Per label instructions
By age and weight
Every 4 hours PRN pain
Yes
No
Phenylephrine HCL OR
Pseudoephedrine HCL
Guaifenesin (Robitussin or
Mucinex) OR
Guaifenesin DM (Robitussin
DM or Mucinex DM)
Diphenhydramine (Benadryl)
By mouth (tablets)
Every 4 hours PRN nasal congestion
Yes
No
Yes
No
Yes
No
Yes
No
Loratadine (Claritin) OR
Cetrizine HCL (Zyrtec) OR
Fexofenadine (Allegra)
By mouth (elixir, tablets or
capsules)
By mouth (tablets)
By mouth (tablets)
By mouth (tablets)
Per label instructions
By age and weight
Per label instructions
By age and weight
Per label instructions
By age and weight
Per label instructions
By age and weight
10 mg
10 mg
180 mg
Yes
Yes
No
No
Yes
No
Phenol (Chloraseptic Spray)
Cough Drops
Apply topically (oral)
By mouth (lozenge)
Per label instructions
1 lozenge
Yes
No
Yes
No
Tums (Calcium Carbonate)
By mouth (chewable tablets)
Yes
No
Famotidine (Pepcid) OR
Ranitidine (Zantac)
Loperamide HCL (Imodium)
By mouth (tablets)
Yes
No
Yes
No
Simethicone
By mouth (capsules)
Yes
No
Maalox
By mouth (suspension)
Yes
No
Lactase (Lactaid)
By mouth (caplets)
Yes
No
Docusate sodium (Colace)
By mouth (capsule)
Per label instructions
By age and weight
Per label instructions
By age and weight
Per label instructions
By age and weight
Per label instructions
By age and weight
Per label instructions
By age and weight
Per label instructions
By age and weight
Per label instructions
By age and weight
Yes
No
By mouth ( tablet or exlixir)
By mouth ( tablet or exlixir)
By mouth (tabs or capsules)
Every 4 hours PRN congestion
Every 4 hours PRN cough.
Every 6 hours PRN allergies or insect
bites
Daily PRN allergy symptoms
Daily PRN allergy symptoms
Daily PRN allergy symptoms or
itching unrelieved by topicals
Every 2 hours PRN sore throat
Every 2 hours PRN cough/sore
throat
Every 2 hours PRN acid indigestion
Daily PRN indigestion or
supplement to allergic response
After loose stools
1-2x daily PRN gas
Every 4 hours PRN upset stomach
With first bite of dairy for lactose
sensitive children
1-3x daily PRN constipation
BRING THIS COMPLETED FORM WITH YOU TO CAMP
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MEDICATION
ROUTE
DOSAGE
MAY BE
SCHEDULE & INDICATIONS
ADMINISTERED
Psyllium husk (Metamucil)
By mouth (capsules)
Alcohol/vinegar Ear Drops
In ears
Hyland’s Earache drops
In ears
Eye Drops (Sodium
Carboymethycellulose OR
Saline solution)
Aloe Vera Gel
Bacitracin/ Neomycin sulfate
/Polymyxin (Triple anitibiotic
Ointment OR
Bacitracin Zinc/
Polymyxin (Polysporin OR
Bacitracin
Hydrocortisone Cream 1%
Antifungal Cream
(Clotrimazole 1% or Tolnftate
1% or Miconazole nitrate 2%)
Burn Relief Gel (Lidocaine
HCL)
Orajel
Calamine /Zinc oxide
Diphenhydramine HCL/Zinc
acetate OR
StingEze OR AfterBite OR
Calamine/ Zinc Oxide OR
Chiggerex
EpiPen (Epinephrine)
Apply topically, ocular
Per label instructions
By age and weight
Per label instructions
Apply topically
EpiPen Jr(Epinephrine)
Per label instructions
By age and weight
5 drops 50/50 mix
1-3x daily PRN constipation
Yes
No
After swimming to prevent
swimmer ear
PRN earache
Yes
No
Yes
No
Every 4 hours PRN dry, irritated
eyes
Yes
No
Per label instructions
Apply PRN sunburn
Yes
No
Apply topically
Per label instructions
Apply 1-3x daily PRN minor cuts
Yes
No
Apply topically
Apply topically
Per label instructions
Per label instructions
Apply 3-4x daily PRN skin irritation
Apply twice daily to soothe itching
Yes
No
Yes
No
Apply topically
Lidocaine HCL 2.5%
Apply 3-4x daily PRN minor burns
Apply topically, oral
Apply topically
Per label instructions
Per label instructions
Apply 1-4x daily PRN oral pain
As needed PRN itching
Yes
Yes
No
No
Apply topically (spray or
cream)
Per label instructions
Apply 1-4x daily PRN itching
Yes
No
Intramuscular (IM) or
subcutaneous (subQ)
injection
Intramuscular (IM) or
subcutaneous (subQ)
injection
1 autoinjector 0.3
mg if over 66 lbs
PRN allergic emergency. May
repeat 1 X after 15 minutes while
transporting to emergency facility
PRN allergic emergency. May
repeat 1 X after 15 minutes while
transporting to emergency facility
Yes
No
Yes
No
1 Jr autoinjector
0.15 mg for 33- 66
lbs
ADDITIONAL/ALTERNATIVE MEDICATIONS TO BE ADMINISTERED AT CAMP
MUST INCLUDE ALL PRESCRIPTION MEDS, VITAMINS, & OVER THE COUNTER MEDS
MEDICATION
ROUTE
DOSAGE
SCHEDULE
COMMENTS
Physician/Healthcare Provider Signature:__________________________________ Date:_______________
Practice Address:_____________________________________________________________________________________________
Phone Number:_______________________________________________________________________________________________
Parent Guardian Signature:__________________________________________ Date:_______________
BRING THIS COMPLETED FORM WITH YOU TO CAMP
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