Old Sierra Historical Ranch Medication Permission Form

Camper’s Name ___________________________

Non-Prescription Medications

In the event that your child suffers from a minor ailment, which does not require a doctor, for example, minor cold symptoms, cough, headache, allergies, cramps, stomachache, it may be appropriate to administer non-prescription medication as follows;

1. Tylenol:  Dosed by your child’s weight for headache, fever, and minor pains.

2. Sudafed:  A decongestant only, which does not cause drowsiness, for nasal congestion and post-nasal drip.

3. Decongestant / Antihistamine combination:  For allergy symptoms, which make camp activities uncomfortable, such as persistent sneezing, and itchy watery eyes.

4. Tums:  This very safe source of calcium is useful for minor stomach discomfort due to stress and/or excess acid.

5. Throat spray or lozenges:  This medication stops throat discomfort instantly, and is very useful while waiting for the Tylenol to take effect.

6. Expectorant / Cough Suppressant:  This medication is useful for a dry non-productive cough.

7. Diarrhea Medication:  If more than one episode of diarrhea, Capacitate tablets will be given according to the labeled directions.  Persistent diarrhea will be treated with Imodium AD.

8. Ibuprofen:  Also known as Advil or Motrin.  This medication is useful for discomfort that is not well relieved by Tylenol.

Please indicate your wishes by placing an “X” in the appropriate box:

Old Sierra Historical Ranch has my permission to give the above listed     non-prescription medications.

  I do not want Old Sierra Historical Ranch to give non-prescription medications.

  Please list any non-prescription medication, which you do not want your child to take. ________________________________

  Please list any non-prescription medication to which your child has had, or may have an adverse or allergic reaction to. ____________________________

Prescription Medications:

Prescription medications must be in the original container, with physician’s instructions.

Medication                               Dosage/Times                          Reason for Med.

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Parent/Guardian Signature__________________________   Date ___________.