CAMP LAUGHING LOON MEDICAL RELEASE FORM
Summer 2010
Camp Laughing Loon is requesting that you have your doctor sign the release form below that allows the Camp Laughing Loon Directors to dispense medicine to your child during the camp day. Prescription medication that is to be taken at camp must be brought in the original container from the pharmacy. (Pharmacists will give you another bottle for the camps dose if you request it.)
If this form is not received in the camp office 14 days prior to your child attending camp, an alternate week must be scheduled.
If you have any questions about this policy, please call Deb Harriman at 247-6329. Thank you for your
cooperation in this matter.
Name of Child: _______________________________________________________________________
Name of Medication: __________________________________________________________________
Dosage Amount and Time: _____________________________________________________________
Any Special Instructions: _______________________________________________________________
Physicians Name and Phone No.: ________________________________________________________
Physicians Signature: _________________________________________________________________
Date: __________________________________
This form must be returned, signed by your doctor, 14 days prior to your child attending camp.
Please mail to: CLL, PO Box 201, East Waterboro, ME 04030
Or Fax to: 247-6339
I give my permission for non-medical camp directors to supervise administration of the above medication
to the above named child.
Signature of Parent/Guardian ____________________________________ Date ___________________
Rev. 11/08
click here for self admin. medical form
