PARENT/GUARDIAN
CONSENT FOR MEDICAL ADMINISTRATION
PROVISION
FOR DAY FIELD TRIPS
Dear
Parent/Guardian,
Please complete one of the items below if your child
regularly takes medication at school.
Please note that over-the-counter medications will not be available on
the field trip, your child may bring his/her own in the original
container. If your child requires any emergency medication (i.e. inhaler,
Epi-pen), please refer to the second part of item #1.
1. I give permission for my son/daughter to
self-administer his/her medication on the field trip if the school nurse
determines it is safe and appropriate.
I understand that my son or daughter will pick up the required
medication ________________________ (name of medication) from the school nurse
on the day of the field trip.
If
the following medications are necessary, I will provide my son/daughter with
his/her own
___ Epi-pen___ antihistamine___ insulin
and/or___inhaler for self-administration.
I also understand that the attending trip leader will be given a list of
all students taking medications on the field trip.
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SIGNATURE OF PARENT/GUARDIAN |
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3.
I give permission to the school nurse to delegate the administration
of _____________________ (name of
medication) for my son/daughter to a designated adult who will be attending the
field trip. I understand that the
school nurse shall instruct the designated adult on how to administer the
medication to my child. I also understand that the attending trip leader will
be given a list of all students taking medications on the field trip.
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SIGNATURE OF PARENT/GUARDIAN |
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Revised 10/21//03