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Cadet Applicant Name

Primary Doctor

Practice Name*

Prescribed / Preplanned Medications*

All medication must be provided to the Camp Medical Staff at Camp Cadet Registration and must be an amount sufficient for the entire week. The medication will be kept and administered by the Medical Staff for the entire week. Specific exceptions may be made.

Is the Cadet prescribed an Epinephrine (EPI Pen™) Medication? (If yes, it is required at camp) YesNo
Is the Cadet prescribed an Inhaler? YesNo
Will the Cadet be taking prescribed medication for the week of camp? YesNo
Will the Cadet be taking over the counter medication on a preplanned basis for the week of camp? YesNo

If you answered YES to ANY of the above questions please list the medication on the “Medication Log form”

If you answered NO to ALL of the above questions please write “None” in the “Medication Name” section of the “Medication Log form”

As Needed Medications*

Medications selected below are over the counter medications which can be administered by the Camp Medical Staff or a qualified designee.

General Health*

Does the Cadet Applicant have any food allergies or special dietary needs? YesNo
If Yes, please describe
Does the Cadet Applicant know when regular medication is required? YesNo
Does the Cadet Applicant have any other medical condition that should be known? (Detail below) YesNo
Medical Conditions details

Notice will be made in a timely matter if an emergency incident is incurred.

The undersigned Parent/Guardian hereby consents to/and grant permission, should the necessity of medical care arise, to the furnishing of medical treatment and hospital services as ordered or recommended by a qualified attending physician, including the administration of an anesthetic, laboratory procedures, medical or surgical treatment, x-ray examination or other hospital services.

This will further certify that the undersigned, does hereby release and discharge the Pennsylvania State Police, Camp Cadet of Lancaster County, Camp Cadet of Chester County, its officers, agents, instructors and employees from any and all claims, demands, damages, suits, actions which may, can or shall have by reason of any illness, injury or accident incurred or suffered by the above named Cadet Applicant while traveling to, attendance at or participation in the Camp Cadet program.

Parent / Guardian Name*
Parent / Guardian E-mail*