2023 6th Grade Camp - Camp Medication Permission | Immaculate Conception of Dardenne Catholic School

Please complete the online version of this form AND print your summary response page or confirmation email containing your responses to include in the Ziploc bag along with the medication.

While at camp, if we have questions regarding this medication, we will call you using the information provided on this form.

Student First Name*

Answer Required

Student Last Name*

Answer Required

Parent 1 First & Last Name*

Answer Required

Parent 1 Cell Phone*

Number Required

Parent 2 First & Last Name

Answer Required

Parent 2 Cell Phone

Number Required

Name of Medication*

Answer Required

Dosage (include how often to give)*

Answer Required

Time(s) to give medication:*

Select all that apply.

Answer Required

at breakfast

at lunch

at dinner

before bedtime

Other:

If you marked 'other' above, please use the space below to explain.

Answer Required

Days Medication should be given at above indicated time(s):*

Select all that apply.

Answer Required

Daily

Monday

Tuesday

Wednesday

Thursday

Friday

Other instructions or directions for the dispensing of this medication.*

If none, please type 'none'. And if you ONLY need to fill out this medication form, then click "submit" at the end and close your browser. You DO NOT need to redo forms you already filled out.

Answer Required

Please fix the highlighted areas below before submitting.

2023 6th Grade Camp - Camp Medication Permission