Instructions for Administering Medication

Please send this form with the Camper Full Name of Camper:
Name, cell phone and email address of primary contact for questions relating to camper’s medication:
Cell phone number:
E-mail address: * required
Name of camper’s primary physician:
Phone number:

Medications taken daily:
Please indicate the name of the medication with dosage, number of pills, and time medicine should be given.
Time Given Name of Medicine Dosage Number of Pills
Before breakfast:
At breakfast:
At dinner:
At bedtime:

Special instruction for any of the medications listed?

Medications to be given only as needed:
Indication (reason to administer medicine) Name of Medicine Dosage Number of Pills

Seizures Does the camper have seizures?
Yes No
Are there any known circumstances that may cause a seizure such as heat or fatigue?

When was the camper’s last seizure?

If camper experiences a seizure:
Do you want emergency medical services to be called? Yes No
Do you want to be called? Yes No

Instructions if a camper has a seizure:


Camp Atlantic,, provides a beach vacation to adults with intellectual disabilities. is able to participate in the camp's activities with the following restrictions:

If you have any questions about the camp's activities, contact Tom Ingoldsby at or at 703 863-9485.


Please send with the participation at the start of camp written confirmation of the participant's vaccination against COVID-19.

Relationship to Camper:

Please make sure that you have included enough medication for the length of the camp!

Verification code:
Re-type verification code:
This is a security to check to ensure you are a human user.