Microsoft word - otc form

“OVER THE COUNTER” MEDICATION RECORD
(“OTC”)
This record MUST accompany your camper’s health history form. Please complete the entire form accurately, review it
with your daughter and sign and date below.
Camper Name___________________________________________________Age______Height_______Weight_______
Camper Allergies___________________________________________________________________________________
I, _______________________, give permission for my daughter_________________________, to receive the following
“OTC” medications on an “as needed” basis. Unless directed otherwise, medication will be administered as directed by
package labeling.

“OTC” Medication (Please mark with a check in the appropriate space)
YES NO COMMENTS

Acetominophen – Tylenol or generic (minor aches and pain) ___ ___ ___________
Aloe Vera Gel/ Lotion – (sunburn) ___ ___ ___________
Ambesol – (toothache) ___ ___ ___________
Arnica – cream/ ointment (muscle soreness/ bruising) ___ ___ ___________
Athlete’s Foot Products – Tenactin, Desenex, or generic ___ ___ ___________
Bactine – antiseptic (cuts and stings) ___ ___ ___________
Baking Soda – paste (bites and stings) ___ ___ ___________
Benadryl – cream/ capsule/ elixir (stings, bites, colds, allergies) ___ ___ ___________
Betadine – ointment or solution (cleaning abrasions) ___ ___ ___________
Blistex – (chapped lips) ___ ___ ___________
Cepacol/ Halls/ generic – throat lozenges (sore throat) ___ ___ ___________
Campo-Phenique – (cold/ canker sores) ___ ___ ___________
Dacirose/ generic eye wash or sterile saline ___ ___ ___________
Dimetapp Tablets/ elixir – (cold, allergies, cough) ___ ___ ___________
Dimetapp Tablets/ non-drowsy – (cold, allergies, cough) ___ ___ ___________
Dramamine Tablets – (bus sickness) ___ ___ ___________
Epsom Salt – (minor infections) ___ ___ ___________
Hydrocortisone Cream – Cortaid and/ or Caladryl (itching) ___ ___ ___________
Hydrogen Peroxide – (antiseptic) ___ ___ ___________
Ibuprofen– Advil, Motrin, generic (minor aches, pains, cramps) ___ ___ ___________
Imodium AD/ generic – (diarrhea) ___ ___ ___________
Insta Glucose – (lowered blood sugar) ___ ___ ___________
Kaopectate –(diarrhea) ___ ___ ___________
Lice control products – (for minor outbreaks, if severe,
camper will be sent home)
Midol – (cramps) ___ ___ ___________
Milk of Magnesia – (constipation) ___ ___ ___________
Mylanta – (upset stomach/ gas) ___ ___ ___________
Polysporin/ Neosporin/ generic antibiotic ointment – (minor scrapes, cuts) ___ ___ ___________
Robitussin Elixir – (colds, coughs, allergies) ___ ___ ___________
Salt, Table (sore throat gargle) ___ ___ ___________
Sore Throat Spray – generic brands (sore throat) ___ ___ ___________
Sudafed – pills/ elixir (colds, allergies) ___ ___ ___________
Sunscreen without Paba ___ ___ ___________
Swim Ear – (for water in the ear) ___ ___ ___________
Tavist-D – (allergies) ___ ___ ___________
Tiger Balm/ generic – (muscle aches) ___ ___ ___________
Tums– (indigestion, gas) ___ ___ ___________
Vaseline – night time use only (dry skin, problematic nosebleeds) ___ ___ ___________
Vicks Vapor Rub – (colds) ___ ___ ___________
 
Parent Signature________________________________________________                            Date____________________ 
Camper Signature_______________________________________________                            Date____________________ 
Thank you for your cooperation and help. We appreciate your time to complete this record, as it will help to make your  camper’s stay at camp a healthy and positive experience.  ALL BLANKS MUST BE FILLED IN! 

Source: http://www.girlscoutsla.org/documents/OTC_Form.pdf