Gcds.net

STEp 1:  MEDiCal anD EMERGEnCY FORM SiDE 1
additional forms are available in the Business office and at www.camp.gcds.us
this medical form needs to be completed for aLL CamPErS and must be on file in the nurse’s office prior to the opening of camp. parents of GCDS
students must complete Section 1, sign, and date. no CHILD may start camp until his/her completed form has been received. Section a: must be
completed by parent/guardian. Section B: Side 2 of this form must be completed by a physician. Section C: aUTHORizaTiOn FOR THE aDMiniSTRaTiOn OF
MEDiCinE form must be completed by a parent/guardian for all children that may require the administration of medication at camp.
Section a:

List two persons who would come and care for your child in case of sickness or injury when parents cannot be reached.
Circle conditions or diseases child has had: The camp nurse may administer:
Tylenol Y / n
Motrin Y / n
Benadryl Y / n
Please note any other facts relating to your child’s health which you feel could be important or helpful to the camp.
Parent’s authorization and consent to medical treatment: Understanding that my child may need emergency medical treatment during camp or at camp activities while he or she attends the
GCDS Camp, I authorize the Camp, through its nurse or other qualified person, to administer such first aid or other minor medical treatment as shall be deemed best under the circumstances,
and I consent for my child to receive such treatment. I understand that the camp will attempt to notify me (or my spouse) in the event of an emergency requiring immediate medical care for
my child, and if the Camp is unable to notify me, it will have my child treated by a duly qualified physician at the nearest emergency facility. I also understand that neither medical nor accident
insurance is provided by the Camp and that the responsibility for providing such coverage rests with me as a parent or guardian for my child.
X
Signature of parent or guardian responsible for fees
Do not rEtUrn tHIS form UntIL SiDE 2 IS ComPLEtED.
STEp 2:  MEDiCal anD EMERGEnCY FORM SiDE 2
additional forms are available in the Business office and at www.camp.gcds.us
Section B: to BE ComPLEtED BY PHYSICIan
Date of initial immunization
Date of Booster Doses
result _________________________________________________________________________________ please note history of any of the following diseases or conditions:
asthma ________________________________________________________________________________________________________________ Diabetes _______________________________________________________________________________________________________________ Heart Disease, incl. rheumatic fever ______________________________________________________________________________________ neurological Disorders, incl. Epilepsy _____________________________________________________________________________________ Chronic or serious illness ________________________________________________________________________________________________ Birth Defects or injury ___________________________________________________________________________________________________ operations ____________________________________________________________________________________________________________ Speech Difficulty _______________________________________________________________________________________________________ Hearing Difficulty _______________________________________________________________________________________________________ Does the camper wear glasses or contact lenses? ____________________________________________________________________________________________ Scoliosis Examination ______________________________________________________________________________________________ Date ___________________ List any illnesses, injuries, or operations which would assume importance in camp participation: __________________________________________________________________________________________________________________________________________________________________________________________________________________List any diet restrictions:_______________________________________________________________________________________________________________________________________________I have examined this student and found him physically fit to participate in sports and camp activities. this student may be given the non-prescription medications as needed indicated by the parents: motrin, tylenol, and Benadryl.
X
physician Signature
Mail to: the Greenwich Country Day School
STEp 3: aUTHORizaTiOn FOR THE aDMiniSTRaTiOn OF MEDiCaTiOn FORM
additional forms are available in the Business office and at www.camp.gcds.us
If you wish to have the camp nurse administer your child’s medication during camp hours, you must complete and return this form
along with the  MEDiCal anD EMERGEnCY forms. medications must be in the original bottle with the pharmacist’s label. this form must
be renewed annually. Please bring the medication to the nurse on the first day of camp. Only the camp nurse will accept medication.
Section C:
TO BE COMplETED BY paREnT/GUaRDian
I hereby request that the camp nurse (or administrator’s designee) administer medication as prescribed by my child’s physician.
name of Camper I hereby release the Greenwich Country Day School and its employees from any and all liability arising from the administration of this medication.
X
parent/Guardian Signature
TO BE COMplETED BY pHYSiCian FOR EVERY MEDiCaTiOn
Dates for administration (mm/dd/yy)If Prn, signs and symptoms for administering medicationPossible Side Effects X
physician Signature
SElF-MEDiCaTiOn RElEaSE
Student must be in Grade 9 or older (exceptions are inhaler and Epipen) physician Signature
parent/Guardian Signature
request that (name of camper) _____________________________________________________ be permitted to self-administer the fol owing medication ___________________________________________ at school. He/she has been instructed in and understands the purpose and appropriate method and frequency of use. He/she will only be carrying the exact dosage for that camp day on his/her person.

Source: http://www.gcds.net/uploaded/Camp_Forms/Summer10/Medical_Emergency_Form10.pdf