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NOW Ministries Leadership Camp Medication Form
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* Indicates required question
Email
*
Your email
CAMPER INFORMATION:
Camper's First Name
*
Your answer
Camper's Last Name
*
Your answer
Camper's Cell Phone Number
Your answer
PARENT/GUARDIAN INFORMATION:
Parent or Guardian's First Name
*
Your answer
Parent or Guardian's Last Name
*
Your answer
Parent or Guardian's Phone
*
Your answer
EMERGENCY CONTACT(S):
Emergency Contact #1 - Name
*
Your answer
Emergency Contact #1 - Phone
*
Your answer
Emergency Contact #1 - Relationship to Camper
*
Your answer
Emergency Contact #2 - Name
*
Your answer
Emergency Contact #2 - Phone
*
Your answer
Emergency Contact #2 - Relationship to Camper
*
Your answer
ALLERGIES:
Any known allergies? (if yes complete section below)
*
Yes
No
Food:
Yes
No
Clear selection
If yes, explain:
Your answer
Medication:
Yes
No
Clear selection
If yes, explain:
Your answer
Plants:
Yes
No
Clear selection
If yes, explain:
Your answer
Insect bites/stings:
Yes
No
Clear selection
If yes, explain:
Your answer
MEDICAL CONDITIONS:
Any medical conditions?
Yes
No
Clear selection
If yes, explain:
Your answer
MEDICATIONS:
List all medications currently used, including any over-the counter medications. (Medication Name, Dose (mg, mL, etc.), Frequency, Reason for Medication)
Your answer
Will these medications need to be given during camp?
Yes
No
Clear selection
Please list the following:
Medication Name and Directions on Bottle (number medications i.e. 1. Med A, 2. Med B, etc.)
Your answer
Date medication should be given (number medications i.e. 1. Med A, 2. Med B, etc.)
Your answer
Time medication should be given (number medications i.e. 1. Med A, 2. Med B, etc.)
Your answer
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