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Drc & src minor health addendum

SESAME/ROCKWOOD CAMPS
PO Box 385, Blue Bell, PA 19422Fax (610) 279-4463 DIAMOND RIDGE CAMPS/CONFERENCE CTR.
Winter Office-PO Box 1862 • Blue Bell, PA 19422Fax (610) 279-4463 After June 10th - PO Box 297, Jamison, PA 18929Fax (215) 343-8849 Minor Staff Member’s Name: ____________________________________________Date of Birth:____________
OUR HEALTH CENTER IS STAFFED BY NURSES AND CERTIFIED FIRST AIDERS.
THE HEALTH CENTER PERSONNEL MAY NOT DIAGNOSE OR PRESCRIBE MEDICATION OR TREATMENT.
In order to relieve minor staff member’s distress when ill, the Camp Health Personnel needs your written permission to administer the following over-the-counter medications. Medications will be administered only when deemed necessary by Camp Health Personnel, and only at recommended weight/age dosages as listed on the product label. Staff are not allowed to keep any medications with them at camp for the safety of all campers and staff.
Please place your initials (not a check mark) next to either a “yes” or “no” for each of the following over-the counter medications. Do not leave any blanks. If no, indicate a substitute that you will sent to camp.
1. FOR PAIN, FEVER, CRAMPS, HEADACHE - PLEASE INDICATE YOUR PREFERENCE OF: ! _______ YES, Camp has my permission.
! _______ NO, I wil send _____________________.
2. FOR ALLERGIC REACTION TO INSECT BITE/STING - BENADRYL® OR GENERIC DIPHENHYDRAMINE.
_______ NO, I will send _____________________.
3. TO RELIEVE ITCHING (POISON IVY/INSECT BITE/RASH) - ANTI-ITCH TOPICAL (BENADRYL® SPRAY/ _______ NO, I will send _____________________.
If you send in an alternate over-the counter remedy or prescription medication, it must be kept at the Health Center. All medications sent from home must be in the original container, and if prescription, prescribed in the name of the staff member. All medications must be properly labeled with name, dosage and times(s) to administer.
In order to care for your child, it is important for us to know how he/she last reacted to bee/insect stings. If previously stung, what type of reaction did he/she last have? Our protocol is to remove the stinger when possible, apply ice at site of bite/sting and observe minor. Benadryl® will be administered if deemed necessary by Health Center Staff. If symptoms indicate, Epi-Pen® will be given (if supplied by parent), Benadryl® administered, minor will be transported to the nearest hospital and you will be notified. INITIAL in all appropriate spaces below.
_______ No History - has never been stung! ! _______ Mild Swel ing only at place bitten/stung! _______ Severe Swel ing and/or difficulty breathing _______Ice & Benadryl® !_______Epi-Pen® used _______Taken to hospital Check here if anyone else in your family has experienced a severe allergic reaction to bee/insect stings.
Signature of Parent/Legal Guardian __________________________________________ Date ______________
! If there is any additional information that the Camp Health Center should know concerning the minor staff member, please ! check box at left and give details on the back of this form. Thank you.

Source: http://www.srdaycamps.com/wp-content/uploads/2013/07/SRC-Staff-Health-Addendum-for-Minors.pdf

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