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Non-Prescription Permission

Non-Prescription Medication List
2005 Camp Jessie Bloom

Dear Parents,

We have doctor approval to administer the below non-prescription medications in the event of any illness or injury we might encounter at camp.  The below products will be administered by are Camp Health Supervisor according to physician’s medical orders.  Please place your initials next to any medication that you DO NOT want your daughter to receive while at camp.

 Please send this document in by June 15, 2005

  Camper’s Name:  _______________________________Phone:  _________________

Address:   _____________________________________________________________

Parent/Guardian: _______________________________________________________

I do not want my daughter to receive the medications I have initialed above.
I give my permission for my daughter to receive any of the medications not
initialed, at the Camp Health Supervisor’s discretion. 

 _________________________________________________________
Parent/Guardian Signature and Date

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