download | print

A History of Seizures *   Allergic Reactions to:  
Diabetes *   Insect stings/bites *
Hypoglycemia *   Penicillin *
Low Blood Pressure *   Other Drugs *
Asthma *   Food *
Inhaler sent to camp *      
Epipen *      
Medication used for allergies
Allergy medication sent to camp? *  
Should medications be sent on trips?  

Any condition requiring daily medication (at home or camp)? *
Medication and dosage for above  
Medication sent to camp? *  
Has your camper had a TETANUS BOOSTER? *
If yes, when?  

* If any medication is coming into camp, it must be accompanied by a Parent and Physician Authorization Form that includes the camper’s name, the drug name, amount to be given, and time to be given. Prescriptions and “over the counter” medications MUST BE IN ORIGINAL LABELED BOTTLES OR CONTAINERS. For prescription drugs, pharmacies will provide a duplicate empty bottle which is labeled and can be sent to camp.

I hereby give permission to the New York Fashion Accessories Camp (NYFAC) to provide routine health care, administer prescribed medications, and seek emergency medical treatment including the ordering of x-rays, administering of anesthesia, or routine tests, as necessary. I agree to the release of any records necessary for insurance purposes. I give permission to NYFAC to arrange necessary related transportation for me/my child.

I understand that attempts will be made to contact parents/guardians (and the emergency numbers listed on this form, as necessary) before initiating this authorization. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by NYFAC to secure and administer treatment, including hospitalization, for the person named above.

This completed form may be photocopied for trips off the premises.

To Mail - Print out form with Check and send to:
New York Fashion Accessories Camp (NYFAC) Jennifer Siletski PO Box 104 Millburn, NJ 07041

©2013 NY Fashion Accessories Camp   Website Designed by Cathy Henszey  
Join Our Mailing List: