355 West Main Street, Suite 150, Malone, NY 12953

Email campoverlook@cornell.edu

Phone: (518) 483-4769 or Fax: (518)483-6214

www.4hcampoverlook.org

2 0 1 8 S u m m e r C a m p

P a p e r A p p l i c a t i o n A p p l y o n l i n e : 4 h c a m p o v e r l o o k . o r g / s u m m e r 2 0 1 8

Camper Information—Please print

Camper Name _______________________________________________Sex: F M Date of Birth ______ /______ /______ Grade as of 9/2018: _________________

Parent/Guardian Names ________________________________________________________ Street/P.O. Box #________________________________________________

City __________________________ State _____________ Zip __________________ Home Phone: (_____)________________ Cell Phone: (______)_____________

Work Phone: (______)_____________ Email ____________________________________________________ Ethnic Identity& Race (optional) ___________________

How did you hear about 4-H Camp Overlook? I am a Previous Camper/Parents are Alumni/Friend/Newspaper/School/Website/Facebook/Agency _________________

4-H Club Member? Y N If Yes, club name: ___________________________________This will be my ____________ year attending 4-H Camp Overlook.

COUNTY of Residence ________________________ Bunkmates: All cabin assignments are first come, first served. Bunk Mate requests must be mutual to be honored.

I would like to bunk with: (limit: 2 bunkmates) ____________________________________ /______________________________________________________________

Office Use Only

Postmark Date Check #

Name on Check Amount

Sponsored by: Scholarship

Camp Enrollment—Please write the week or program your camper will be attending. Use the extra space for multiple weeks

Program/Week ___________________________________ & _________________________________________________ & _____________________________________

Class Choices - Traditional Camp ONLY ( Choose 4 class periods) ______________________________ ______________________________ _______________________

__________________________________________ Alternate Class choice _____________________________________________________________________________

Class Choices (if going multiple weeks) _______________________________________ ____________________________________ _____________________________

__________________________________________ Alternate Class choice _____________________________________________________________________________

Make checks payable to: “4H Camp Overlook” and include your child’s name on the check. Checks must be in USD

I give permission for my child to participate in 4-H Camp Overlook activities and have completely read the entire 2018 application and additional forms and will cooperate

with all regulations. I release Cornell Cooperative Extension, 4-H Camp Overlook, its staff, and the Board of Directors from all liability for any actual or alleged injury to me or

my child including death or damage to or destruction of property arising out of any act or omission on part of myself or my child in connection with the 4-H Camp Overlook

Program. I give permission for any photos of my child to be used in promotions (brochure, website, newspaper, ads, posters, etc.) concerning 4-H Camp Overlook.

SIGNED: _____________________________________ DATE: ________________________

Parent/Guardian Signature

Traditional Overnight Camp

Ages 8 to 19 Cost is $419

Arrive on Sunday between 1:00 and 3:00pm

Depart on Friday at 7:00pm

Week 1 Sunday, July 1 - Friday, July 6

Week 2 Sunday, July 8 - Friday, July 13

Week 3 Sunday, July 15 - Friday, July 20

Week 4 Sunday, July 22 - Friday, July 27

Week 5 Sunday, July 29 - Friday, Aug. 3

Week 6 Sunday, Aug. 5 - Friday, Aug. 10

Cloverbud Camp

Ages 6 to 8 Cost is $195

Arrive at 10am — Leave at 1pm

C.B. 1 Thursday, June 28 - Saturday, June 30

C.B. 2 Sunday, August 5 - Tuesday Aug. 7

MAAPs Wilderness Trips

Alpine Adventures Ages 11+ Cost is $419

Mountaineers Ages 13+ Cost is $419

Arrive on Sunday between 1:00 and 3:00pm

Payment: A minimum deposit of $150.00 PER program PER

camper must accompany this application (full payments will

also be accepted). Deposit is non-refundable once a

camper is offered one of their chosen weeks. You will receive an invoice with balance due via email. Please make

sure your email address is accurate. Full balances are due June 1st, 2018. To qualify for a scholarship we must

have a completed Scholarship Form submitted with your camp application by April 15th.

Alpine 1 Sunday, July 1 - Friday July 6

Mountain Sunday, July 15 - Friday July 20

Alpine 2 Sunday, July 29 - Friday, Aug. 3

Weeks attending ____________________x $419 = _____________

MAAPs Program attending ____________x $419 = _____________

Cloverbud attending _________________x $195 = _____________

Additional Class fees (if applicable) _____________

Total Amount Due $____________

Deposit Enclosed: (circle one) Check / Cash / Send Invoice

Deposit Amount: $____________

A $150 non-refundable deposit is due for each camper and each session. Spots are not held for applications received without deposit.

A l l A p p l i c a t i o n s a r e a c c e p t e d o n a f i r s t c o m e / f i r s t s e r v e b a s i s ( w i t h d e p o s i t ) u n t i l c a m p i s f u l l .

4-H Camp Overlook Cancellation Policy

- Once a camper is given a slot in their requested session (s), the $150.00 deposit fee is non-refundable.

- Tuition refunds (less the $150.00) deposit will be granted when a cancellation is made 10 or more days in advance of the camp session.

- Once the 10-day advance notice period is past, tuition refunds (less the deposit fee) will be granted only in the cases of camper sickness or a

sickness/death in the camper’s family.

- If a camper leaves camp for any other reason beside injury/family emergency, no refund will be made unless approved by the 4-H Camp Advisory

Board, e.g., no refunds are given for campers who go home due to homesickness, medication problems, inappropriate behavior, etc.

- In situations where a refund is given, the refund is pro-rated at $25.00 per day, up to $100.00 total.

DON’T WAIT! APPLY NOW!

For the past few years camp has filled to capacity so PLEASE apply early to ensure your first choice of weeks.

Spaces are filled on a first come/first served basis.

Things to Remember

Before June 1st a $150 deposit will reserve your spot at camp. After June 1st full payment must accompany all applications. We do not accept

credit cards with paper applications, only with Online Registration.

Canadian residents must send a bank money order or check in USD funds.

There will be a $25 fee for checks returned to Camp Overlook.

All scholarship applications MUST be RECEIVED by April 15th in order to qualify. If you receive tuition assistance from another agency you most

likely will not qualify for our scholarship assistance program. Scholarships are given out to residents from Franklin or St Lawrence county with

pressing financial need.

Scholarship applications MUST be accompanied by an application (paper or online) and the $150 deposit.

Confirmation replies for paper applications will not go out until after April 1st. You will receive an invoice with the balance due along with an

informative email a few weeks before your child's week that will answer all of your questions. All communication will be sent to the email

provided on this application. Please make sure the email is checked regularly! Please call our office 518.483.4769 with any questions.

Health forms must be filled out each year. A physical exam is not required for attendance, however, we strongly recommend that your child has a

thorough annual physical exam. Many doctors will not sign the health form without a recent exam. Medication Information Section which must

be signed by a physician for your child to receive over-the-counter and/or prescription medications. An immunization record must be attached to

the health form or an immunization exemption must be pre-submitted and approved by the board of directors. A health check and head lice

screening will be performed by our Health Staff during registration at camp.

Campers with developmental disabilities should contact the Camp Administrative Office at 518-483-4769 or by email at

campoverlook@cornell.edu to verify that we can accommodate you.

4-H Camp Overlook’s Camp Store will be open Sunday during registration and Friday evening at closing camp fire (except Friday, August 10th) for

campers and parents to purchase T-shirts, sweatshirts, pajama pants, hats, etc. Monday, Tuesday, and Wednesday campers will visit Camp Store

at 4pm and will be able to choose a healthy snack and a small piece of candy. These snacks are included in the cost of camp, therefore campers

do not need to bring extra money to receive them.

For more information on any of our programs, please visit our website

4 h c a m p o v e r l o o k . o r g

We have photos, descriptions, and so much more!

“Cornell Cooperative Extension actively supports equal educational and employment opportunities. No person shall be denied admission to any

educational program or activity or be denied employment on the basis of any legally prohibited discrimination involving, but not limited to, such

factors as race, color, religion, political beliefs, national or ethnic origin, gender, sexual orientation, age, marital or family status, veteran status, or

disability. Cornell Cooperative Extension is committed to the maintenance of affirmative action programs that will assure the continuation of such

equality of opportunity.”

2018 Summer Camp Activities

Pathfinder Learn essential skills for backpacking and hiking in the wilderness! Campers will participate in activities such as pitching a tent, practicing Leave No Trace principles, orienteering, and an introduction into outdoor cooking. Later in the week Pathfinder campers will take an afternoon hike up nearby Owls Head Mountain to put their new learned skills to the test, and even cook dinner on top of the peak!. This activity is offered to campers of all ages and fills in one class period per day. Pathfinder is part of our wilderness leadership series, for more information on our backpacking program, visit the M.A.A.P. page on our web-site! Offered Weeks 2, 4 & 6. Wilderness Survival (2 Class Periods) Ever wonder what you would do if you got lost in the woods? Do you like to be outdoors and explore? In “Wilderness Survival”, you’ll learn essential skills to help you be prepared for any adventure outdoors. You’ll learn how to make shelters, build fires, set up a camp, find your way in the woods, and identify safe and unsafe plants. At the end of the week you will put your skills to the test! Eco-Explorations How well do you know the creatures that make the Adirondacks their home? In this activity you will learn about the wildlife that lives in the water, mud, and woods around 4-H Camp Overlook. You will also learn how to recognize these creatures by their tracks, sounds, droppings, what they eat and where they live. Get involved with many hands-on activities, and find maybe animals you didn’t know existed in your backyard! Fishing Whether you take fishing seriously or do it as a leisure activity, there’s nothing like feeling a tug on the end of your line! Camp-ers will learn about fishing techniques, fish habitat and safety, while relaxing on our beautiful fishing dock. Poles and equip-ment provided. NEW! Backyard Farmer In this activity you will get your hands dirty! Campers will help tend our raised garden beds, collect and plant seeds, learn about worms and compost, insects and pollinators, taste fresh herbs and vegetables straight from the garden, and explore our natural environment in hands-on garden based learning. You will also be learning about our camp chickens, help collect eggs, and make a new poultry friend or two! NEW! Future Pioneers This activity is a compilation of many previous favorite camp classes. You will build test parachutes and catapults, go on a Geo-caching treasure hunt, and even launch a rocket! Combine science and creativity in the ultimate camp adventure.

Adventure Course

Adventure 1 : Campers in the Level 1 participate in a variety of games and fun group initiatives designed to develop trust and teamwork. Adventure Class 2: (2 Class Periods) Age limit 12 and up. Participants focus on team-building and communication skills through the use of group initiatives and low ropes elements. Campers also learn spotting and safety techniques as they move through our ropes course. Age limit 12 and up or 11 and up with Level 1 experience. Adventure Course 3: (2 Class Periods) Age limit 13 and up with at least 2 years of Adventure Course experience. Campers will spend the majority of their time on low & high elements including the Burma Bridge and the Zip Line. Groups will learn advance problem solving and leadership skills.

Archery

Archery Novice Minimum age 8. No previous archery experience necessary! Campers learn the parts of the bow and arrow, archery safety, and practice to devel-op shooting skills. Archery Intermediate Minimum age 10 and 1 year of camp archery experience. In this level campers will improve upon their aim and shooting skills, while working on more advance targets and games. Archery Advanced Minimum age 12 and 2 years of camp archery experience. Campers learn the parts of a compound bow and develop advanced shooting skills. Designed for those who have archery experi-ence, or have taken our previous archery classes. Curriculum includes challenging games and archery challenges! Sailing Campers will be able to identify the main parts of a sailboat, learn rigging and shoring procedures and understand how to right an overturned or tipped sailboat. Campers wear life jackets and are under the supervision of Red Cross Certified Lifeguards. Canoeing and Kayaking J-Stroke, C-Stroke or Draw? Learn the difference between these types of canoe strokes and glide effortlessly across the water! This continued favorite activity builds skill during the week, and if the weather cooperates includes a trip to a nearby island for a picnic lunch! Arts & Crafts This perennial camp favorite incorporates a wide variety of art forms including textiles, painting, sculpture, miniatures, crafts from recycled materials and much more! This activity allows campers to take home several handmade camp memories. Since the curriculum changes year to year, there is always something new to create.

NEW! Leatherworking In this activity you’ll learn the tools and skills including punching, cutting, and lacing necessary for creating a unique and one-of-a-kind leather craft. After campers learn the basics, you will move onto a more advanced independent project of your choosing: wallets, coin purses, bracelets, book covers-the opportunities are endless! Offered Weeks 1, 3, 5 ONLY Drama: Improvisation Do you love acting, playing games, and thinking on your feet? Develop your stage presence while hamming it up with friends in this exciting performing arts class. Campers will have a blast while working on under the guidance of our most charismatic counselors. Offered Weeks 2, 4, 6 ONLY NEW! Ultimate Overlook In this activity, you’ll be playing some of Camp Overlook’s oldest and most cherished group games. Every day will be a new adventure as you play Capture the Flag, Medic, Monkey Ball, and more. You may even learn a new game or two. The goal of this class is to be active, have fun, and become a Rec Field Hero. Air Gun Ages 10 and up. Child must be able to hold and support the weight of the gun. Feel the sense of accomplishment as you improve your tar-get score with every shot! Campers will use air-powered pellet guns to learn gun safety, range procedures and basic marksmanship, while under the careful supervision of 4-H Shooting Sports staff. Advanced Air Gun Ages 11 and up with 1 year camp Air Gun experience. Advanced Air Gun is for campers 11 and up who have already taken Air Gun and want to further their skills. These camp-ers will learn new shooting positions and have new advanced challenges, as well as more shooting time on the range. Camp Newspaper Campers get to try their hand at being a reporter. They can choose to interview counselors, write an article or short story, think up fun horoscopes, poll the camp, make an art page, and more. Each camper will make their own page for the weekly newspaper. Campers in the class will receive their own copy of the newspaper, and will have their work uploaded to the camp website! Camp Cooking (Two class periods) Class size limited to 10 campers per week. Learn basic cooking and backing techniques while cooking camp classics and new favorites! Basic culinary and nutrition skills are covered, and you get to taste all your creations. Now offered all weeks! ~additional $10 fee~ NEW! Sewing In this sewing class, students will learn the fundamentals of sewing on a sewing machine, sewing project constructions, pinning, cutting fabric, as well as important design skills to create their own simple stuffed animal pro-jects. Each student will complete 1-2 stuffed animals in this class to take home! Teacher Bio: Megan Avery is a proud 4-H Camp overlook alumni and is SEW excited to be coming back to 4-H Camp this summer to teach her passion of sew-ing to kids. She owns a sewing studio in Hoboken NJ and has been teaching adults and kids to sew for the last 13 years. Offered Week 2 only – limited class space. Build a Bench (Two activity periods) Limited to 8 campers ages 12 and up. Campers will learn the fundamentals of pioneer woodworking using primitive tools. Campers will then fashion their own half-log wooden bench. Learn a life skill, and bring home a beautiful piece of Adirondack furniture! – Offered week 5 only ~additional $25 fee~ Paddle making (Two class periods) Class size limited to 10 campers ages 12 and up. Have you ever dreamed of carving your very own canoe paddle? Create a work of art that is also functional from Adiron-dack Cherry wood to bring home! Students will learn the basics of woodworking in this activity. – Offered week 5 on-ly ~additional $15 fee~ Counselor in Training Classes (CIT) CIT 1 – Must be age 14 by June 20th. If you are interested in becoming a camp counselor this course is for you! The CIT I program introduces campers to the philosophy of Camp Overlook, including camp traditions, songs, and safety rules. Available Weeks 3, 4, & 5. CIT 2 – Must be age 15 by June 20th. The CIT II program focuses on leadership styles, the importance of communication, developing teamwork, and tech-niques for working with children. Available weeks 3, 4, & 5. CIT 3 – (ALL Class periods) Must be age 16 by June 20. Leadership in the Making. This is a program for campers, 16 years of age, who are looking for a completely unique camp experience! Participants will be involved with all aspects of camp, but be on a separate and specialized learning tract that prepares them for future leadership roles. CIT III’s will spend the morning two class periods with the Camp Director/Assistant Director further developing their skills as emerging camp counselors. The afternoon classes (all three periods) will be spend conducting in-depth team building and leadership activities that are directly applicable to pursuits in school, college and careers. This exciting experience will allow participants to work closely with their peer group, while developing valuable skills and lifelong friendships. 16 year olds interested in this class would register as a traditional camper and choose only this class. Available Weeks 1 and 2 only.

Must be

Received

by

April 15th

Each scholarship application is reviewed by a Selection Committee and need is determined by:

Situational Need: Please make sure to fill out the back side of the form completely.

Financial Need: household income does not exceed the following levels (see below)

Total People in Household 2 3 4 5 6 7 8

Gross Monthly Income $2,392 $3,011 $3,631 $4,251 $4,871 $5,490 $6,110

Gross Yearly Income $28,694 $36,131 $43,568 $51,005 $58,442 $65,879 $73,316

Scholarship Application Procedure:

1. Answer ALL questions completely.

2. Submit a Summer Camp Application and a $150.00 deposit for each child. Scholarships are NOT available to cover the deposit fee.

Online applications are encouraged.

3. Campers will be notified (by email or phone) with the amount of their scholarships along with an invoice for the remaining

amount due (if any). If you can not accept this scholarship please notify camp as soon as possible. If you do accept the scholarship

award your balance (if any) is due on June 1st. Your online account will reflect the scholarship.

Section 1 Child’s Information—Please list each child applying for a scholarship

Name Address Age Gender 4-H Member

M F Y N

M F Y N

M F Y N

Have any of these children received a scholarship in the past? Y N If Yes, who?

Did this child attend camp with that scholarship? Y N

Scholarships do not cover the $150 deposit. What amount would you need for this child to attend camp? $________________________

Attending: ______ Cloverbud Camp _________ Traditional Camp

Section 2 Parent / Guardian Information—ALL adults living in the home with the child(ren)

Name Address Daytime Phone Evening Phone

______ Franklin

______ St. Lawrence

$___________________

Deposit Amount

Office Use

355 West Main Street, Suite 150, Malone, NY 12953

Phone: (518)483-4769 Fax: (518)483-6214

For Franklin and St. Lawrence County Campers Only.

2018 Scholarship Application

Please complete the other side.

Section 3 You must list ALL sources of income in this section for All persons 18 or older living in the home with

the child applying. Application will not be considered if this section is not fully completed.

List names of ALL adults

18 or older living in

the household

What is the relationship

to camper? Employed Place of Employment

TOTAL MONTHLY

INCOME

Y or N

Y or N

Y or N

Section 4 Please describe any specific financial situation that your family faces this year that would make it difficult for you to pay

the camp fee for your child(ren):

Section 5 What would you consider the single most important reason for your child to attend 4-H Camp Overlook this

year? What do you hope your child gets out of the experience?

Ages of ALL dependent children living in the home: ______ ______ ______ ______ ______ ______

Scholarship applications must be received by April 15th in order to qualify.

Scholarship application must include a complete application (online or paper) and $150 deposit per child.

Type of Assistance Received (check all that apply)

Food Stamps Temporary Assistance Child Support; Monthly Amount $ _________

WIC Free School Lunches Social Security; Monthly Amount $ _________

HEAP Reduced School Lunches Unemployment; Monthly Amount $ _________

Veterans Benefits; Monthly Amount $ _________ Other: Name ______________________ Monthly Amount $ ________

Office Use only: Date received_______________________ EMAIL FAX MAIL Completed Signed Health Form ____YES _____NO Immunization Records Received____________________(Date)

4-H Camp Overlook Health Form - Due June 1st, 2018

Please allow your health care provider ample time to complete the physician section on the back and return it to us. This form needs to be completed every year. Health Forms are not carried over from previous years. Campers cannot attend camp without this form.

Your health care provider can send the completed form to us at:

4-H Camp Overlook, 355 West Main Street, Suite 150, Malone, NY 12953 or fax: 518-483-6214 or email: CampOverlook@cornell.edu

Child’s Name: ____________________________ Parent / Guardian Name:__________________________________________

Birth date: _______/_______/______ Age: ________ Sex: M F Weight: ________ lbs.

Home phone (______)_______________ Work phone (______)___________________ Cell phone (______)___________________

Home Address: __________________________________ City: ____________________ State _______ Zip code __________

If not available in an emergency, notify:

1. Name: _________________________________ Phone: (______)____________ Cell: (_______)_______________

Address: _______________________________________________________________________________________________

2. Name: _________________________________ Phone: (______)____________ Cell: (_______)_______________

Address: _______________________________________________________________________________________________

Name of camper’s physician: ______________________________________________ Phone: (______)_________________ Date of last physical examination: _______/________/________

Family Insurance Coverage Name of Plan: _________________________________ Health Insurance Company: _________________________________ Name of Employer (if group): ________________________________________________________________________________ Name of Policy Holder: ________________________________ Policy Number: ____________________________________ Health History (check if appropriate):

ADD/ADHD Bed Wetting Diabetes Heart Defect / Disease Sinusitis

Asthma Bleeding / Clotting Frequent Earaches Hypertension Sleepwalking

Athlete’s Foot Convulsions Frequent Colds / Sore Throat Menstrual Problems MRSA

Allergies Penicillin Food: Please Specify

__________________

__________________

Environmental: Please Specify ________________________

________________________

Other Drug Allergies: ____________________

____________________

Other Allergies: _____________

_____________

Peanuts

Insect Stings

Latex

Additional Information: To ensure a successful summer for your child as well as other campers, please provide any information about the

participant’s behavior and physical, emotional, or mental health which the camp should be aware of:______________________________________________ ________________________________________________________________________________________________________________________ For children with developmental disability or special needs; a parent may be contacted prior to arrival to ensure we can accommodate them. If we do not

have the resources to meet your child's needs you will be notified and given a full refund.

Does your child require an aide at school? Y or N Does your child receive any special services at school? Y or N

Current Condition or Special Needs: Please describe any recent illness, injury, existing medical condition, restriction or special need that your child has.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Special Dietary Needs: ____________________________________________________________________________________________________ Do we have permission to help administer Bug Spray or Sunscreen that you provide for your child? (circle) YES NO Emergency Authorization This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the adult leader in charge to hospitalize, secure proper anesthesia, or to order injection or surgery for my son or daughter. Parent Signature: __________________________________________________________________________ Date: _______________________

Our Health Director will review this health form before your child arrives at camp. To secure a place for your child at 4H Camp Overlook, we must receive your health forms by JUNE 1st. Due to increased competition for enrollment and the absolute necessity to review health forms before the camper

arrives at camp, if we do not receive your health form by this date your child will be in jeopardy of losing his/her spot at camp this summer.

Circle Week (s) Attending

CB1 CB2 1 2 3 4 5 6 Mount Alpine 1 Alpine 2

Camper’s Last Name: ________________ First Name: ___________________ DOB: _____/_____/_____ Weight _______ lbs.

Immunization Record – required unless exemption is requested and granted by board of directors. Please attach a copy of the camper’s recent immunization record.

? Check here if immunization record is attached (required)

Health Care Recommendations: Please complete with patient’s current regimen for both scheduled and prn medications – use 2nd page if needed.

Please bring all regularly taken medications (prescription and over the counter) to the camp nurse when registering. Medications must be in original bottles.

Health Care Provider Name: ________________________________________________________ Phone: _(______)___________________ Address: _______________________________________________________________________ License # _________________________ Health Care Provider Signature: ___________________________________________________ Date: _________/_________/_________

Prescription Medications – attach sheet if needed If a licensed health care provider does not sign this form, the camper will not be given any prescription or over the counter medication.

Drug Name Reason for Taking When is it given: Dosage How it is given Date

Started

? Breakfast

? Lunch

? Dinner

? Bedtime

? Other time:_____________

? Breakfast

? Lunch

? Dinner

? Bedtime

? Other time:_____________

? Breakfast

? Lunch

? Dinner

? Bedtime

? Other time:_____________

Mental, Emotional and Social Health History: Circle Yes or No for each statement. Has this child:

Ever been treated for attention deficit disorder (ADD) or attention deficit / hyperactivity disorder (AD/HD)? Y or N

Ever been treated for emotional or behavioral difficulties or an eating disorder? Y or N

During the past 12 months, seen a professional to address mental/emotional health concerns? Y or N

Had a significant life event that continues to affect the camper’s life? (Death of a loved one, family change, adoption, survived a disaster etc.) Y or N

If you answered Yes to any of the statements above please explain in this space.

The camper is undergoing treatment at this time for the following conditions: (describe below) ? None.

Over the Counter Medication provided by camp. Please circle yes or no

Tylenol PO - Chewable tabs, elixir or tabs

Per label instructions by age/weight Q 4 hr prn for pain or fever >______F Yes No

Ibuprofen PO - Chewable tabs, suspension, or tabs

Per label instructions by age/weight Q 6 hr prn for pain or fever >______F Yes No

Robitussin PO - Syrup Per label instructions by age/weight Q 4 hr prn for cough Yes No

Pepto-Bismol PO - Chewable tabs, or liquid

Per label instructions by age/weight Q 30 min to 1 hr prn for diarrhea

(no > 8doses/24hr) Yes No

Tums PO - Chewable tabs Per label instructions by age/weight BID-TID prn for stomach upset Yes No

Dimetapp PO – Suspension or tabs Per label instructions by age/weight Q 6-8 hr prn for nasal congestion/drainage

Yes No

Benadryl PO - Elixir, chewable tabs, or pills

Per label instructions by age/weight Q 6 hr prn for allergic reaction

(hives, insect bite) Yes No

Imodium AD PO – Tabs Per label instructions by age/weight 1caplet after 1st BM, and ½ caplet after

each subsequent loose BM Yes No

Loratadine PO – Chewable tabs Per label instructions by age/weight 1 tablet daily for allergies Yes No

Zyrtec PO – Tabs Per label instructions by age/weight 1 tablet daily Yes No

Topical ointments & Spray

PO – Ointment or spray Per label instructions Prn for cuts, scrapes & burns Yes No

Physician’s Section

Medical Information Provided Is Strictly Confidential. Health Forms are due for review by June 1st.

4-H Camp Overlook, 355 West Main Street, Suite 150, Malone, NY 12953, or fax at 518-483-6214, or email CampOverlook@cornell.edu