2018 Sedgwick Science Camp Forms Student Registration and

2018 Sedgwick Science Camp Forms: ü Student Registration and Health Form (front of pink form) ü Authorization to Administer Medication (back of pink form) * ü Special Dietary Needs Form (front of blue form) ü Allergy and Anaphylaxis Action Plan (back of blue form)* *requires doctor signature and clinic stamp How to turn in medication ü Prescription ( original box, pharmacy label attached) ü OTC (new, sealed, in box, with dosing device) ü Nurse office hours to check meds Important dates

2018 Sedgwick Science Camp Student information Insurance Info ie: Kaiser, Blue Cross etc Emergency Contact not parent Parent information Need 24/7 phone number

Ok to film student Check box HEALTH INFORMATIO N Check all boxes that apply (stings-if never stung write never) Does your student take ANY medication? Including over the counter 2018 Sedgwick Science Camp Write explanation for all checked boxes Don’t forget to sign

2018 Sedgwick Science Camp Provided over the counter medications No need to pack If yes to some and no to others Mark yes, cross out meds not able to take If yes to ALL meds mark Yes If No to ALL meds mark NO

Physician completes this section Write all meds to be given—Dr. write as if prescription Med Dose Route Time Condition If as needed must have frequency (as needed every 4 hours) 2018 Sedgwick Science Camp EEmergency Medications only ((A(Epipens and asthma inhalers) Does student have permision to carry and self administer as needed? Yes check YES No check NO Doctor’s signature and office stamp

2018 Sedgwick Science Camp Don’t forget to sign

Circle foods student does not eat (does not include picky eaters) f. If Student Allergic complete entire form How is allergy triggered? Ingestion Contact inhalation 2018 Sedgwick Science Camp If medication listed you must complete medication authorization form (back of pink form) and Allergy Action Plan (back of blue form)

2018 Sedgwick Science Camp Yes to epipen then complete Medication Authorization form (back of pink form) and Allergy Action Plan (back of blue form) IMPORTANT INFORMATION IF STUDENT ALLERGIC TO EGG SOY OR CORN CALL (831 -722 -8222 2 WEEKS PRIOR TO CAMP

Physician completes form 2018 Sedgwick Science Camp Student information What are they allergic to Antihistamine: Write as prescription Medication Dosage Route Time If as needed include frequency What medication for which symptoms Circle dosage for epipen

2018 Sedgwick Science Camp Physician information Signature and Office stamp

2018 Sedgwick Science Camp

2018 Sedgwick Science Camp

2018 Sedgwick Science Camp Student can not turn in medication bags. Parents MUST in medication to health office. Medicaiton will not be accepted from students. turn

2018 Sedgwick Science Camp Important Dates to remember Ø February 26, 2018 Turn in Camp forms to teacher Ø March 26, 2018 Parents turn in medication bags Ø March 26 9: 00 am-10: 30 am Medication office hours with Julie Low RN Ø March 27, 9: 00 am-10: 30 am Medication office hours with Julie Low RN Ø March 28, 9: 00 am-10: 30 am Medication office hours with Julie Low RN Ø April 27, 2018 Final day medication bags will be accepted Ø May 21, 2018 Board bus to go to camp Ø May 24, 2018 Pick up student and belonging at Sedgwick

2018 Sedgwick Science Camp Freguenly Asked Questions: • • Who do I contact with questions • Medical or Medication questions—Julie Low low_julie@cusdk 8. org • General camp questions—Your child’s teacher Can I use the medication already at school • Yes—you must contact Julie Low and make arrangements