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Daily/Regular Medication Consent Form
By filling out this form, you are agreeing for your child's medications to be packaged and managed by Mednow (
www.mednow.ca
), as is Camp Northland policy this summer.
DEADLINE: TUESDAY, JUNE 7, 2022
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* Indicates required question
Email
*
Your email
Parent First and Last Name:
*
Your answer
Parent phone number:
*
Your answer
Parent Email (if different than the one above):
*
Your answer
Camper First and Last Name:
*
Your answer
Camper's Birthday:
*
MM
/
DD
/
YYYY
Campers Health Card Number (Please include version code)
Your answer
Current Pharmacy Name:
*
Your answer
Current Pharmacy Phone number:
*
Your answer
Current Pharmacy address (if you have it):
Your answer
How long will the camper be staying at camp? Please provide the start and end date of their stay.
*
Your answer
Does the camper have allergies to any medications?
*
Yes
No
If you answered yes, please list which medications the camper is allergic to.
*
If you answered 'No' to previous question, please skip.
Your answer
Please list ALL medications that are required by the camper including: tablets, capsules, inhalers, creams, injectables, etc. Please also include any medications that are required on a when needed basis.
*
Your answer
Any other relevant health information/supplies needed:
Your answer
Send me a copy of my responses.
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