ECHO HILL Over-The-Counter Medication Approval Form
Parent Permission for Echo Hill Ranch to Dispense "Occasional" Over-The Counter Medications to their child
(New for 2013)

To be in full compliance with Best Practices in Camp Nursing, we are required to have on file this overthe-counter medication form, completed by the camper’s parents, before such medications can be dispensed to your child. Over-the-counter (OTC) medications are drugs that do not require a prescription and are purchased ‘over-the-counter’ at pharmacies, convenience stores, etc.

With your approval, the Camp Nurse or her designee will dispense OTC medications as needed and at recommended child dosages free of charge to campers.

PLEASE INITIAL EACH MEDICATION FOR WHICH YOU ARE GIVING PERMISSION FOR ECHO HILL TO DISPENSE or CHECK APPROVAL FOR ALL MEDICATIONS
Name of Camper(s):

(If you have more than one child at camp and their OTC approval is the same, then you can list all of their names above. If they need different OTC medications approved, please submit a new form for each child. )

I approve all medications listed below. (Or check below which individual medications are approved).
TOPICAL
Antibiotic cream (Bacitracin Cream, Polysporin)
Hydrocortisone cream (Cortaid)
Benadryl Cream (Caladryl lotion)
Sunscreen
Oral products containing benzocaine (oragel, chloraseptic)
Eye drops for dryness or irritation (non-antibiotic)
Burn gels (Microcyn, Water Jel)
ORAL:
Ibuprofen (Advil, Motrin, Nuprin)
Acetaminophen (Tylenol)
Antacid (Mylanta, Maalox, Tums)
Cold Medication (Robitussin, Decongestants: liquid or nose spray)
Antihistamine (Benadryl, Loratadine)
Cough syrup (Pertussin, Vicks, plain or menthol cough drops)
My signature below authorizes the Camp Nurse or her designee to dispense the above checked, over-the-counter medications to my child.
Signature of Parent or Guardian:
Date: