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Blue Mountain Ranch Permission to Treat Form
Please Check
*
I hereby give permission to the medical personnel selected by the Camp Director to provide routine medical care; to administer medications; to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my son/daughter:
*
Indicates required field
Camper's Name
*
First
Last
Please Check:
*
In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Camp Director to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for the trips out of camp.
Signature of Parent/Guardian:
*
Date Signed:
*
Please Check:
*
I hereby give permission for Blue Mountain Ranch to administer the following over-the-counter medication if the nurse deems it necessary. Dosages will be administered according to the directions on the bottle unless a physician directs otherwise.
Over-the-Counter Medicine
*
Tylenol/Advil headaches
Ibuprophen/Midol for menstrual cramps
Pepto Bismol for upset stomach
Imodium AD for diarrhea
Calamine Lotion/Cortaid
Check all that are approved
Other:
*
Signature of Parent/Guardian:
*
Date Signed:
*
Submit Form