Word of Life Camp Individual Medication Form Last Name: ______________________ First Name: ______________________ The following may be administered to your if needed, while at camp. Medication Dosage Approval Acetaminophen (Tylenol) Per label instructions Yes No Ibuprofen (Advil) Per label instructions Yes No Diphenhydramine HCI Per label instructions Yes No (Benadryl) Guaifenesin (Robitussin or Per label instructions Yes No Mucinex) Parents or guardians, please list your child’s prescription medications, over the counter medications, vitamins, herbs and or dietary supplements. Camper must be able to administer own injections. Medication Route Dosage Frequency and Comments Name Indications
Word of Life Camp Individual Medication Form Last Name: ______________________ First Name: ______________________ The following may be administered to your if needed, while at camp. Medication Dosage Approval Acetaminophen (Tylenol) Per label instructions Yes No Ibuprofen (Advil) Per label instructions Yes No Diphenhydramine HCI (Benadryl) Per label instructions Yes No Guaifenesin (Robitussin or Mucinex) Per label instructions Yes No Parents or guardians, please list your child’s prescription medications, over the counter medications, vitamins, herbs and or dietary supplements. Camper must be able to administer own injections. Medication Name Route Dosage Frequency and Indications Comments