PARENT/CAMPER KIT - the Cooperstown Dreams Park

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7 Cooperstown Dreams Park Medical Services Camper Examination and Medications Camper’s Name_________________________________ Date of Birth___________ Team Name ___________________________________ This form is to be completed by a Physician, Physician Assistant or Nurse Practitioner. I examined this individual on __________ (must be within 12 months from the start of camp). In my opinion, the above camper is is not able to participate in an active camp program. The camper is under the care of a physician for the following conditions: _____________________________________________________________________ Treatments to be continued at Camp: __________________________________________ ________________________________________________________________________ Medications: New York State Department of Health requires that camps have an individualized set of standing orders for each camper attending camp. The list below is of the standard over the counter medications campers may require while at camp. The medications will only be administered at the discretion of a Registered Professional Nurse. A licensed health care provider needs to initial in the Yes box if they wish the child to be eligible to receive the medication at camp and sign the bottom of this form. Yes No Yes No Yes No Yes No Yes No Yes No Acetaminophen PO per label instructions by age/weight every four hours as needed for pain or fever >100.5 Ibuprofen PO per label instructions by age/weight every 6 hours as needed for pain or fever >101.5 Diphenhydramine PO per label instructions by age/weight every 4-6 hours as needed for allergies Mylanta PO per label instructions by age/weight three to four times a day as needed for an upset stomach. Dimetapp PO per label instructions by age/weight every 6-8 hours as needed for nasal congestion /drainage. Robitussin PO per label instructions by age/weight every 4 hours as needed for cough. Daily/ Prescribed Medications and PRN medications the child will need while at camp. Drug Name Route Dose Schedule/ Indication Comments All Medications Must be in the original containers. Health Care Providers Name: _______________________________ Phone #_________ Address_______________________________________ License # _________________ Health Care Providers Signature _____________________________ Date ___________ Provider and/or practice stamp:
8 COOPERSTOWN DREAMS PARK PARENTAL AUTHORIZATION AND CONSENT FORM I, _____________________________________ (please print your name), am the _________________________________________________ (mother/father/legal guardian) of ___________________________ (name of child) who is enrolled as a camper at Cooperstown Dreams Park during the week of ________________________ (date) on the __________________________________________(name of team) baseball team. I hereby authorize and entrust the below listed individuals to act in my place, to exercise full parental authority (including medical care authorization) and control over my child while at Cooperstown Dreams Park. Please list coaches from your team roster and other persons whom you authorize to act on your behalf to exercise parental authority and control over your child while at Cooperstown Dreams Park: (please print names of coaches) 1._________________________________ 5.__________________________________ 2._________________________________ 6.__________________________________ 3._________________________________ 7.__________________________________ 4._________________________________ 8.__________________________________ Date:_____________________________ ____________________________________ (Parent/Guardian Signature)
Page 1 and 2: 2013 PARENT/CAMPER KIT “A Summer
Page 3 and 4: 2 Agreement to Participate With Wai
Page 5 and 6: Cooperstown Dreams Park Medical Ser
Page 7: 6 Team Number________________ Team
Page 11 and 12: 17 10 Friday Early Check-In (Sign-u
Page 13 and 14: 12 4:30 p.m. Family Orientation, Op
Page 15 and 16: 14 • 24-Hour medical and first ai
Page 17 and 18: 16 Daily Itinerary • Meals 6:30 a
Page 19: 18 Rules of Dreams Park (continued)
Page 23: 22 • Street Address: Emergency In

PARENT/CAMPER KIT - the Cooperstown Dreams Park

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