Summer Programs Medical Forms

Dear Parent or Guardian:

We look forward to welcoming your child to one of the many exciting camps being held at Avon Old Farms School. To complete the registration process, the following forms must be completed and returned one week prior to the start date of camp:

Required Medical Forms

• Health History Form 
  
• Medical Waiver & Release Form
• Emergency Contact Form
  

Please Note: If your child will not need medication during the course of his or her day, then please disregard the following information and only complete the forms mentioned above.

Our summer programs wish to limit medication usage to camper self-administration (of a school age). The program will keep the proper documentation on file.  If your child brings to camp an Epi-Pen, inhaler, or other prescribed oral or topical medication, or a non-prescribed (over-the counter) oral or topical medication that may need to be provided, camper must be able to self-administer.

Please review, complete, and return the following forms:

• Self-Administration of Medication Form 
  
• Prescription and Non-Prescription Medication Authorization Form 
• Be sure to read the Administration of Medication Policy below.
  

Administration of Medication Policy

Avon Old Farms Summer Programs will keep on file the following information:

• Prescribed inhalers or Epi-pens or other medications with parent’s consent; and a doctor’s signature.
• Non-prescription oral medications with parent’s consent and a doctor’s signature.

Authorization forms for each, which require a parent’s and doctor’s signature, are available from program staff.

Parent Responsibilities

• It is the parent’s responsibility to inform program staff upon registration that their child has a prescribed inhaler, epi-pen, or other medication.
• The medication must be maintained privately in the child’s bag, so as to be inaccessible to other children.
• Medication forms are required to be signed by parent and physician before the program starts. They must include:
  • The child’s name, address, and birth date.
  • The drug name.
  • The prescribed dose.
  • The method of administration (oral, topical, epi-pen, etc.).
  • The time to be self-administered.
  • The side effects.
  • The prescriber’s name and address.
  • Medications must be in their original container and clearly labeled.

Staff Responsibilities

• Medication will be self-administered by camper, but under close supervision by a staff member.
• Parents shall be notified of any administration errors by telephone. The error will be documented in the child’s camp record.
• Staff will keep accurate documentation of all medications administered by completing the proper paper work, which will be kept in the program director’s files. Individual administration records shall include:
  • The date the medication was administered.
  • The time it was administered.
  • The dose that was administered.
  • Any comments

If you have any questions about the administration of medication during camp, please contact the Program Co-Directors.

Sincerely,
Brian Cugell and Andy Riemer
Avon Old Farms Summer Programs Co-Directors

500 Old Farms Road
Avon, CT 06001
(860) 404-4180