PARENT/GUARDIAN
CONSENT FOR MEDICAL ADMINISTRATION
PROVISION
FOR OVERNIGHT FIELD TRIPS
Dear
Parent/Guardian,
Please note
there is no nurse going on this field trip.
If your child will need any medication (including Tylenol or
Ibuprophen), he/she will need to bring his/her own in the original
container. All medications must be
listed on the back of this sheet and the appropriate section (usually section
#1) signed below.
STUDENT |
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1. I give permission for my son/daughter to
self-administer his/her medication as indicated on the front of this form on
the field trip if the school nurse determines it is safe and appropriate.
If the following medications are
necessary, I will provide my son/daughter with his/her own
_____Epipen_____antihistamine_____insulin and/or_____inhaler for
self-administration on the field trip.
I also understand that the attending trip leader will be given a list of
all students taking/carrying medications on the field trip.
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SIGNATURE OF PARENT/GUARDIAN |
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DATE |
2. 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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DATE |