Summer 2009
Re: Consent for OTC Medications
Dear Parent(s)/Guardian(s),
Please fill out this box, and take this form to your child’s physician to be completed and signed.
Child’s Name: __________________________________________
Please List All Medication/Food/Other Allergies: _____________________________________________________
_____________________________________________________________________________________________
Dear Physicians,
In order to be in compliance with regulations set forth by the Cattaraugus County Health Department, a physician’s
approval must be obtained before any over-the-counter medications may be administered to children attending our
residential summer camp.
The following OTC medications will be available for campers at our medical lodge. Camp New Horizons Medical Staff will
always follow the manufacturer’s dosage instructions unless otherwise instructed by a physician.
Please check or initial by all OTC medications which you are approving to be administered to the child by Camp New
Horizons Medical Staff and sign below. Please feel free to write any notes or special instructions.
Please Trade Name Generic Name Active Ingredients Dosage Route Indications
Check mg/ml
Advil Ibuprofen Ibuprofen 200 mg Oral Pain Relief
Tylenol Acetaminophen Acetaminophen 500mg Oral Pain, Fever Relief
Children’s Pain Acetaminophen Acetaminophen 160 mg Oral Liquid Pain, Fever Relief
Relief per 5 ml Suspension/
Sub lingual
Advil Migraine Ibuprofen Ibuprofen 200 mg Oral Migraine Relief
Ibuprofen Ibuprofen Ibuprofen 200 mg Oral Pain Relief
Children’s Ibuprofen Ibuprofen buprofen 100 mg Oral Pain Relief
per 5 ml Suspension
Children’s Bayer Children’s Aspirin Acetylsalicylic Acid 81 mg Oral Headache Relief
Aspirin
Midol Maximum Menstrual Relief Caffeine 60mg, 500mg Oral Menstrual Relief
Strength Pyrilamine Maleate
15mg, Acetaminophen
500mg
Benadryl Allergy Relief Diphenhydramine HCL 25 mg Oral Allergy Relief
Children’s Benadryl Children’s Allergy Diphenhydramine HCL 12.5 mg Oral Allergy Relief
Relief per 5 ml Suspension
Pepto Bismol Bismuth Subsalicylate Bismuth Subsalicylate Mfr. Oral Stomach Ache/Cramps
Instruct.
Children’s Pepto Bismuth Subsalicylate Bismuth Subsalicylate Mfr. Oral Stomach Ache/Cramps
Bismol Instruct.
Imodium A-D/ Calcium Carbonate Loperamide HCL 2 mg 500 mg Oral Anti-Diarrheal
Tums USP per capsule
After Bite Kids Children’s Bite Relief Eucalyptus Oil 1.3% Mfr. Topical Anti-Itch
Instruct.
Hydrocortisone 1% Anti-Itch Cream Hydrocortisone Mfr. Topical Anti-Itch
Cream Instruct.
Calamine Lotion Calamine and Zinc Calamine and Zinc Mfr. Topical Anti-Itch
Oxide Oxide Instruct.
After Bite Eraser Bite Relief Ammonia 3.5% Mfr. Topical Anti-itch
Instruct.
Tussin CF Guaifenesin Dextromethorphan HB Mfr. Oral Cold Relief / Cough
USP 10mg, Instruct. Suspension Suppressant
Guaifenesin USP (liquid)
100mg, Phenylrphrine
5mg
Cough Drops Menthol 5 mg Menthol 5 mg Mfr. Oral drop Cough Suppressant/ Sore
Instruct. Throat Relief
Sore Throat Spay Phenol 1.4% Phenol 1.4% Mfr. Oral spray Sore throat
Instruct.
Oral Gel Benzocaine 20 % Benzocaine 20% Mfr. Oral Mouth Sore
Instruct.
Vaseline Lip Therapy White Petrolatum White Petrolatum Mfr. Topical Lip Care
Instruct.
Artificial Tears Eye Care Polyvinyl alcohol 0.5% Mfr. Drops Eye Care
Povidine 0.6% Instruct.
Saline Solution Saline Solution 0.9% normal saline Mfr. Drops Eye Care
Instruct.
Gold Bond Body Medicated Body Menthol0.15% Mfr. Topical Rashes/Itching
Powder Powder Zinc oxide 1% Instruct.
Vaseline Petroleum Jelly Petroleum 100% Mfr. Topical Skin Care
Instruct.
Icy Hot Muscle Cream Methyl salicylate 30% Mfr. Topical Sore Muscles
menthol 10% Instruct.
Menthol patch Menthol patch Menthol 5% Mfr. Topical Sore Muscles
Instruct.
Neosporin Wound Care Bacitracin 400units Mfr. Topical Wound Care
Neomycin 3.5mg Instruct.
Polymyxin B 5000units
First Aid Cream Wound Care NA Mfr. Topical Wound Care
Instruct.
Burn Gel With/without Aloe Mfr. Topical Burns
lidocaine Instruct.
Sun Block Spf 15-45 NA Mfr. Topical Sun Block
Instruct.
Bug Spray Various brands NA Mfr. Topical Insect Repellent
Instruct.
Rubbing Alcohol Rubbing Alcohol Alcohol 70% Mfr. Topical Wound Cleansing Agent
Instruct.
Hydrogen Peroxide Hydrogen peroxide Hydrogen peroxide 3% Mfr. Topical Wound Cleansing Agent
3% Instruct.
Parent/Guardian Signature: ____________________________________________ Date: _________________
Physician Signature: ___________________________________________________Date:_________________
Please Direct Any Questions To:
Mark McGee, Director of Camp New Horizons
Phone: (716)372-0208x102 / Fax: (716)372-0222 / Email: mmcgee.mhacc@verizon.net