Bounce Delight Glee Clubs Camp Medication/Medical Release

Form
Please complete the information below if your child requires medication of any kind (prescription or
non-prescription) while at camp. An individual form must be completed for each type of medication
required and we only accept the daily dosage amount each day. Asthma inhalers and Epi-pens are the
only medications that are allowed to be in the possession of campers that require them (this release
form must still be filled out for these two exceptions). All other medications must be given to our
designated Camp Director along with this form.

Allergy medication (e.g. Benadryl) and Pain medication (e.g. Tylenol) must be given to Bounce Delight
Glee Clubs staff with this completed form.

Child’s Name: ______________________________________________ Male Female 

Child’s Age: ______ Allergies:

Week Your Child is Attending Camp (please check):

 
Week #1 Week #2
12/21 – 12/24, 2009 12/28 – 12/31/2009

Name of Medication:

_______________________________________________________________________
Date(s) to be administered (Please Check):

Monday Tuesday Wednesday Thursday Friday (N/A)

Child’s Family Doctor (name):

Doctor Tel #: ( ) Health Card #:

Time(s) to be administered: 1. ________________ 2. ________________ 3. _______________

Dose(s) to be administered each time:

_______________________________________________________

I (Parent  Guardian) hereby give permission to Bounce Delight

Glee Clubs for any and all medical attention to be administered to my child
In the event of sickness, injury, accident, etc. while attending camp.

I do herewith authorize the treatment of my child at camp and transfer of my child to a medical facility
as needed until such a time as I may be contacted. I agree to assume all financial responsibility for all
medical care that may be required in such an event. This release is effective for the camp period as
indicated above. I the undersigned have read this and understand its term. I execute it voluntarily and
with full knowledge of its significance.

Parent/ Guardian Signature: _________________________ Date: __________________

Print Full Name: ____________________________ Day Telephone #: ______________