Prescription Medication Form

I, hereby, ________________________________ (Parent/Guardian Name) give the camp health supervisor/athletic trainer permission to hold on the prescription medication and administer as indicated by the prescription. I further acknowledge this medication was prescribed by a licensed physician and that the camp health supervisor may contact that physician with any questions or concerns.

My child’s name is __________________________ and the medication my child will be taking is as follows:
____________________________________________________________________________

The medication is to be given ____________________ time(s) per day.

Please list any other additional information regarding the prescription medication (Please indicate if there is none):
________________________________________________________________________________________________________________________________________________________________

Furthermore, the medication will be kept by the healthcare supervisor/athletic trainer during each session and secured in a locked location overnight. Please be advised that only the amount of medication needed for the duration of the camp should be provided.

Parent/Guardian Signature:
________________________________________________________________________________

Relationship to Camper:
_______________________________________________________________________________

Date: ________________________________________________________________________________

Authorization for the Administration of Medication

Parents/guardians requesting medication administration to their child while at camp shall provide the program with appropriate written authorization(s) and the medication before any medications are administered. Medications must be in the original container and labeled with the child’s name, name of medication, directions for medication’s administration, and date of the prescription. All unused medication shall be destroyed if not picked up within one week following the camper’s departure at the end of camp.

Authorized Prescriber’s Order (Physician, Dentist, Physician Assistant, Advanced Practice Registered Nurse):

Name of Child ____________________________________________________________________

Date of Birth ____/_____/_____ Today’s Date ____/____/____

Medication Name_________________________________________

Controlled Drug □ Yes □ No

Dosage ____________________ Method _______________

Time of Administration _____________

Specific Instructions for Medication Administration
________________________________________________________________________________

Medication Administration: Start Date _____/_____/_____
Stop Date: _____/_____/_____

Is This Medication to be self-administered by the child? □ Yes □ No

Relevant Side Effects of Medication
_______________________________________________________________________________

Plan of Management for Side Effects
_______________________________________________________________________________

Known Food or Drug Allergies? □ Yes □ No    Reactions To? □ Yes □ No     Interactions To? □ Yes □ No

If “yes” to any of the Above, Please Explain:
_______________________________________________________________________________

Prescriber’s Name
_______________________________________________________________________________
Phone Number
(______) _______________

Prescriber’s Address
_______________________________________________________________________________

Prescriber’s Signature
_______________________________________________________________________________

Parent/Guardian Authorization:
□ I Request that medication be administered to my child as described and directed above
□ I request that medication be self-administered to my child as described and directed above

Name of Camp_____________________________ Today’s Date ______/______/______

Child’s Name
_______________________________________________________________________________

Address
_______________________________________________________________________________

Name of Parent/Guardian Authorizing Administration of Medication
_______________________________________________________________________________

Relationship to Child: □ Mother □ Father □ Guardian/ Other (explain) __________________________

Name of Camp Personnel Receiving Written Authorization and Medication
_______________________________________________________________________________

Title/Position _______________Signature (in ink) ______________________________

Commuter Meal Ticket Order Form

Team Name: ________________________________________

Coach’s Name: ______________________________________

Lunch: # of lunches x $9 ___________________________

Dinner: # of dinner x $9_____________________________

Package of 3 lunches and 3 suppers is $54 (Dance Camp July 10-13)
# of campers_________x $54 =______

Total Cost = ________

Package of 3 lunches and 3 suppers is $54.00 (July 14-17)
# of campers__________x $54.00 = ___________

Total Cost =_________

All meal tickets will be picked up at registration

Please make checks payable to: BON APPETIT.

New England Cheer & Dance 2016
November 12, 2016
Reggie Lewis Field & Track Center

Routine Music

We are asking all Coaches/Teams to please E-MAIL their music for each routine to: bassdj.cheer@gmail.com
When you email your music, in the subject line please include:
– Town (ex: Marshfield)
– Team Name (ex: Marshfield B)
– Division (ex: Pee Wee)
– Coach’s Name (ex: Deb Arey)

Your music will be loaded and ready to go the day of competition. Your coach will simply need to press play on our audio system.
We are asking for all music to be submitted by: Wednesday, November 9, 2016

Please feel free to email any questions to this email as well. (bassdj.cheer@gmail.com)

Live Audio Critique

Each competing team will have an Audio Critique of their of routine recorded and emailed to the Coach. This is included with your registration Fee.